Summary Plan Description 2014 Plan Year

Medical Plan for Active

Employees

UnitedHealthcare Health Fund PPO for Non-Exempt

Employees

Table of Contents

How to Use this Book ...................................................................................................... 1Eligibility .......................................................................................................................... 2Enrolling for Coverage ..................................................................................................... 5Cost of Benefit Coverage .............................................................................................. 11When Coverage Begins ................................................................................................ 13Situations Affecting Your Benefits ................................................................................. 14How the Medical Plan Works ........................................................................................ 17Covered Services .......................................................................................................... 25General Limits and Exclusions ...................................................................................... 47Prescription Drug Benefits ............................................................................................. 50Behavioral Health Care ................................................................................................. 59Claims Filing and Appeals ............................................................................................. 62Coordination of Benefits ................................................................................................ 76When Coverage Ends ................................................................................................... 78COBRA Continuation Coverage .................................................................................... 81Important Legal Information .......................................................................................... 83Your Rights Under ERISA ............................................................................................. 88Plan Administration ....................................................................................................... 91

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How to Use this Book This summary plan description (SPD) provides details about the Pitney Bowes Inc. Medical Plan (the Medical Plan). Use this SPD to find answers to your questions about eligibility, coverage, and legal protections.

The Pitney Bowes medical, mental health/substance abuse and prescription drug options are self-insured (with the exception of the Kaiser Group Health Cooperative and the Aetna DMO, which are fully insured). This means Pitney Bowes (the Company) assumes the cost of all claims and expenses. The Company contracts with a claims administrator for claims processing and other administrative services including network management and claims appeals. The Company pays claims on behalf of employees and their covered dependents either through a trust fund established and funded by the Company or from the Companys general assets.

Where you live and the medical option you choose determines your claims administrator.

Each medical option covers a similar range of services and supplies, including preventive care, office visits, hospitalization, prescription drugs and behavioral health care (mental health and chemical dependency treatment). See Your Options section of this document for information about the medical options available to you.

Helpful Tips for Using this SPD Section References: Many of the sections of this SPD relate to other sections of the

document. You may not find all of the information you need by reading only one section. It is important that you review all sections that apply to a specific topic. Also, refer to footnotes and notes embedded in the text. They clarify, offer additional information or identify exceptions that may apply to you.

Covered Services: The Plan provides benefits for many medical services and supplies. You and the Company share the cost of coverage. The Covered Services section provides a description of your cost sharing in relation to each covered service, as well as information about specific services, including pre-authorization/ notification requirements, limitations and exclusions.

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Eligibility To be eligible for coverage under the Medical Plan, you must be:

A regular full-time employee or a buffer employee, or Regularly working at least 30 hours per week, and Actively at work. Eligible Dependents Eligible dependents include your:

Spouse. You must be considered legally married under federal law. Depending on whether your state recognizes same-sex marriage, coverage under the Plan may result in imputed taxable income in that state, as it does for a domestic partner. (See Tax Implications: Domestic Partner Coverage and Same Sex Marriages in the Your Costs section that follows.)

Eligible domestic partner. An eligible domestic partner is a person who is the same or opposite sex as you and with whom you have a relationship that meets the requirements under either 1 or 2 below. (See Tax Implications: Domestic Partner Coverage in the Your Costs section that follows.)

1. You and your partner have had a relationship for at least 12 months, and you and your partner:

Are at least 21 years old, Are financially interdependent, Are not married or involved in another domestic relationship, Are not related to each other and Have lived together for at least 12 months

OR

2. The partnership is registered under a state or local law.

Children up to age 26. This includes your biological, adopted, foster and stepchildren, children placed with you for adoption or for whom you are a legal guardian and children named in a Qualified Medical Child Support Order (QMCSO)* and children of your eligible domestic partner. Dependent coverage ends at the end of the month that your covered dependent child turns age 26, unless a disabled dependent (see below). Once coverage ends,

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your dependent will receive a notice of COBRA Continuation Coverage. (See the COBRA Continuation Coverage section for details.)

*A valid QMCSO is any court-issued judgment, decree or order reflecting the courts determination of a childs right to receive benefits under a health plan in which the childs parent is an eligible participant. A QMCSO must meet certain legal requirements. Pitney Bowes will determine whether a particular order meets these requirements under the law.

Unmarried children of any age who cannot support themselves due to behavioral or physical disability. However, if your child was covered under this Plan and became disabled after his or her coverage ended due to age, you cannot re-enroll your child in the Plan.

Keep in mind:

If you use a Health Savings Account (HSA) to help cover some of your medical costs:

HSA funds should not be used to reimburse domestic partners who are not tax dependents (i.e., they cant be claimed on your tax return). They may be able to open their own HSA account or claim the out-of-pocket expenses on their own tax returns.

HSA funds cannot be used for adult children unless they are tax dependents (can be claimed on your tax return).

Providing Proof of Eligibility When you enroll your dependents for the first time, you must provide proof that they are eligible for coverage, including:

A Social Security number for each dependent. The Social Security number for a newborn child within 60 days of birth. Certification that your domestic partnership meets the eligibility requirements

described above.

You may be asked to provide proof of eligibility from time to time. If you are selected for the Dependent Audit, you must submit:

Proof of a dependent childs eligibility, and/or A copy of your marriage license for a spouse or proof of your domestic partnership. If you do not provide proof when requested, Pitney Bowes has the right to deny coverage and request reimbursement of any claims paid on behalf of the ineligible dependent.

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Disabled Dependent Certification If you enroll a disabled child for coverage, you must provide proof of his or her disability if he or she is older than the age limit. Your claims administrator will request medical evidence of your childs incapacity if you elect to continue coverage for a disabled child over age 26.

If the administrator determines that your child does not qualify as a disabled dependent, your childs coverage will end at age 26. Your child may elect COBRA continuation coverage.

Whos Not Eligible Youre not eligible for coverage if youre regularly working less than 30 hours per week or are a(n):

Leased employee, Temporary employee, Independent contractor, Inactive employee receiving an LTD benefit and who has Medicare as primary

coverage,

Employee of a subsidiary that primarily operates outside the United States unless United States Social Security contributions are made on your behalf or

Employee of a division, unit or subsidiary that does not participate in the Medical Plan.

Dependents Not Eligible for Coverage You may not cover:

A divorced spouse. A married dependent, except where noted. Stepchildren, or children for whom you have legal guardianship or custody other

than your natural and adopted children, if their primary residence is not with you.

Your parents or siblings. Your grandchild(ren). A dependent who doesnt meet the eligibility requirements.

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Enrolling for Coverage You enroll for coverage when you're hired and each year during the annual enrollment period.

If you do not enroll by the deadline stated in your enrollment materials, you will be assigned default coverage. See your enrollment materials for information about the default coverage assigned to new hires and during the annual enrollment period.

Keep in mind that if your dependents are not enrolled by the deadline, you wont be able to enroll them until the next annual enrollment period unless you have a qualified change in status event (see the Special HIPAA Enrollment Rules and Making Changes During the Year sections).

If you have a qualified change in status event or a change in employment status that makes you benefit-eligible during the year, you may be eligible to enroll or make specific changes at that point as well.

Contact the Benefits Center at 1-888-469-7276 with your specific questions.

If Youre A New Hire If eligible, you will automatically receive an enrollment kit at your home. If you enroll, your coverage will be effectiveand contributions will be deductedretroactively to your eligibility date. This means you may have double deductions, that is, deductions for two pay periods, taken out of your paycheck after you enroll.

Coverage Categories You can choose from four coverage categories:

You only, You plus your eligible spouse or eligible domestic partner, You plus your child or children or You plus your family (eligible spouse or domestic partner, plus child or children). Please note: Your eligible dependents must be covered under the same medical or dental option you choose for yourself. However, you do not have to cover the same dependents for medical, dental and vision (for example, you may choose to cover yourself, your spouse and children for medical but only yourself and your children for dental and vision).

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Coverage Options Pitney Bowes offers you a choice of medical options. These include:

Preferred Provider Organizations options PPO

Health Fund PPO

Kaiser and Group Health Cooperative Health Maintenance Organization (HMOs)* You can also decline medical coverage by electing the No Coverage option.

Once you choose a medical option, you will also choose a health plan to administer your benefits.

*Only if you live in certain parts of CA, CO, GA, OR, WA, HI or the Mid-Atlantic Area (for Kaiser) or certain areas in WA (for Group Health Cooperative)

About Your Options Your medical options depend upon where you live. The health plan administrators operate in service areas areas of the country where they contract with providers to deliver the care that you need. Your enrollment materials list the specific options that are available to you in your area.

Prescription Drug and Behavioral Healthcare Coverage Prescription drug and behavioral health coverage is included when you elect medical coverage.

No Coverage Option Pitney Bowes believes that having at least minimum protection against illness and injury is very important and strongly encourages you to have some type of medical coverage. If you elect No Coverage, you will not be able to change this coverage until the next annual enrollment period (unless you have a qualifying change in status event).

Note: Under the Affordable Care Act (the ACA), each individual (including your spouse and children) is required by law to have medical coverage or pay a penalty. If you do not want coverage through Pitney Bowes, you may purchase coverage in the Health Insurance Marketplace. You should be aware, however, that because Pitney Bowes offers you coverage that meets ACA standards, you will not be eligible for a tax credit in the Marketplace and the Company will not share the cost of coverage with you. Also, you must pay for coverage in the Marketplace on an after-tax basis.

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Choosing a Health Plan If youve selected the Health Fund PPO or the PPO Plan, you have two options: Cigna or UnitedHealthcare. Although the price tags and most of the services are the same, there are differences in the resources that the plans offer. You can find more information on the PB BenefitConnect Web site, including information about:

NCQA Accreditationa review of the plans services and clinical quality CAHPs scoresresponses to a survey of members enrolled in the health plan Resources that are available to you Condition management programs Both of the plans offer:

Customer care specialists to help you with questions about your coverage, claims, and billing issues or general questions.

A network of health care providers who have agreed to accept a discounted fee. A team of nurses to help you when you are hospitalized or have a chronic condition

such as diabetes.

Useful Web sites filled with tips, tool and resources. Choosing Providers When you seek medical care, you decide if you want to use doctors, hospitals and other healthcare facilities that participate in a network of contracted providers through the health plan (in-network) or to receive your care from any other qualified doctor, hospital or facility (out-of-network). In-network providers are credentialed by the administrator and agree to accept a discounted fee. If you choose in-network doctors and facilities, you generally receive a higher level of benefits and pay less out of your pocket than if you use out-of-network doctors or facilities.

If you select UnitedHealthcare as your health plan, in-network providers participate in the ChoicePlus network (however, if you live in Dane County, WI, the providers participate in the Options PPO network).

The Premium program recognizes doctors who meet standards for quality and cost efficiency. The quality standards are based on evidence-based medicine and national industry guidelines. The cost efficiency standards are based on local market benchmarks for cost-efficient care. When youre looking for a doctor, you can consider his or her Premium designation when making your choice. Look for the UnitedHealth Premium Tier 1 symbol to quickly and easily find doctors who have been recognized for providing value.

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Primary Care

Family Medicine

Obstetrics & Gynecology

Pediatrics

Internal Medicine

Specialists

Allergy Ophthalmology

Cardiology Orthopaedics-General

Cardiology-Electrophysiology Orthopaedics-Foot/Ankle

Cardiology- Interventional Orthopaedics-Hand

Ear, Nose and Throat (ENT) Orthopaedics-Hip/Knee

Endocrinology Orthopaedics-Shoulder/Elbow

General Surgery Orthopaedics-Spine

General SurgeryColon/Rectal Orthopaedics-Sports Medicine

Nephrology Pulmonology

Neurology Rheumatology

Neurosurgery-Spine Urology

The high performing providers are designated with Tier 1.

If your ID card states that it is the UnitedHealth Premium network, you have access to a network of high performing providers. When you use a physician who has the Tier 1 Premium designation, your coinsurance applied to services that this provider bills will be 10% instead of 20%.

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Making Changes During the Year Once your enrollment period ends, you cannot change your coverage unless you experience a qualified change in status. Enrollment timeframes and examples of qualified change in status events are listed below.

Eligible Qualified Change in Status Events: Enrollment Required Within 30 Days of the Change Marriage or your domestic partner becomes eligible. Divorce, legal separation, annulment or termination of domestic partnership. Birth, adoption or gaining legal custody of a child. Death of your spouse, dependent child or eligible domestic partner. Gain or loss of eligibility for your dependent child. Loss of coverage for you, your dependents, your spouse or your eligible domestic

partner due to your spouses or domestic partners employment or work schedule, cessation of his/her employers contribution towards coverage, or loss of his/her job.

Significant change in your spouses or eligible domestic partners coverage due to his or her employment or work schedule, or loss of his/her job.

Change in dependent childs student status (dental only). Change in residence outside of your current network area for yourself, your spouse,

or your eligible domestic partner.

Your entitlement to Medicare. Eligible Qualified Change in Status Events: Enrollment Required Within 60 Days of the Change (Special HIPAA Enrollment Rules) You or your dependents lose Medicaid or Children's Health Insurance Program

("CHIP") coverage as a result of a loss of eligibility for such coverage, or

You or your dependents become eligible for a premium assistance subsidy under Medicaid or CHIP.

Marketplace Notice There may be other coverage options for you and your family. In fact, under the Affordable Care Act (the ACA), each individual (including your spouse and children) is required by law to have medical coverage or pay a penalty. You may qualify for a special enrollment opportunity for another group health plan for which you are eligible, such as a spouses plan, even if the plan generally does not accept late enrollees, as long as you request enrollment within 30 days.

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In addition, as part of the ACA, you will be able to buy coverage through the Health Insurance Marketplace (Marketplace), even if you are eligible for COBRA. You can see what your premium, deductibles and out-of-pocket costs will be before you make a decision to enroll. You should be aware, however, that:

if you are an active employee, the coverage Pitney Bowes offers you meets ACA standards for affordability and minimum value. As a result you will not be eligible for a tax credit in the Marketplace and the Company will not share the cost of coverage with you. You must pay for coverage in the Marketplace on an after-tax basis.

if you are a COBRA beneficiary, Pitney Bowes coverage meets ACA standards for minimum value. However, if single COBRA coverage costs more than 9.5% of your household income, you may qualify for federal tax credits. You will still need to pay for coverage with after-tax dollars.

How to Make Changes If you have a qualified change in status event, you may change your coverage elections by:

Logging on to the PB BenefitConnect enrollment Web site on Inside PB (go to Life & Career, then Work and Life Benefits, then Health and Wellness) or on the Internet at https://pitneybowes.ehr.com/ess/home/login.aspx, or

Calling the Pitney Bowes Benefit Center at 1-888-469-7276. Please be prepared with documentation to support your qualified change in status event. You cannot submit documentation after the applicable deadline.

In most cases, the change becomes effective on the date of the event. If you dont make your change within the required timeframe, youll have to wait until the next annual enrollment period to change your coverage.

If You Transfer from One Participating Pitney Bowes Business Unit to Another There wont be a break in your coverage as long as there are no gaps in your service with a participating Pitney Bowes business unit. Please note that your costs and Flex$ may change.

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Cost of Benefit Coverage You have a choice of medical options with different price tags based on the coverage level you choose.

You and Pitney Bowes share the cost of medical coverage. The Company provides contributions in the form of Flex$ (Flex dollars) to help you pay for some of your Flexible Benefits Program (Flex) elections, including medical coverage. Your total medical Flex$ are made up of Flex$, Service$ (if your current hire date is before December 31, 1997) and applicable incentive dollars. Your Flex$ are shown on the enrollment Web site.

Note: Your contributions for coverage are deducted from two paychecks per month.

Spouse/Eligible Domestic Partner Surcharge If you elect coverage for your spouse or eligible domestic partner, and he or she waived coverage through his or her employer, youll pay an annual surcharge. The surcharge does not apply if:

Coverage is not available through your spouse/eligible domestic partners employer, or

He or she enrolled in his or her employers plan, or He or she works for Pitney Bowes and waives medical coverage. Tax Implications: Before-Tax Deductions Contributions toward the cost of coverage are deducted from your pay before taxes are taken out. In general, you dont pay federal and most state and local income taxes on this money. You also dont pay Social Security tax on this money, which means your contributions may reduce your total wages for Social Security purposes when these benefits are paid.

Please Note: Certain state and local jurisdictions, such as the State of New Jersey and the city of Philadelphia, may impose state and/or local income tax on your contributions and Flex dollars.

Tax Implications: Domestic Partner Coverage and Same Sex Marriages Although it costs the same to extend medical benefits to an IRS-qualified spouse and to a domestic partner, there is one important difference. You must pay for the cost of coverage for your domestic partner (and his or her children) on an after-tax basis unless he or she qualifies as a dependent under Internal Revenue Code (IRC) Section 152, and you must pay tax on the value of the Company contribution towards your domestic partners (and his or her childrens) coverage (imputed income).

For same-sex married couples living in U.S. jurisdictions that recognize same-sex marriage, the value of medical coverage for a same-sex spouse and his or her eligible dependents will not be included as income for federal or state tax purposes. However,

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for same-sex married couples living in U.S. jurisdictions that do not recognize same-sex marriage, the value of medical coverage for a same-sex spouse and his or her eligible dependents will not be included as income for federal tax purposes, but may be included as income for state tax purposes.

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When Coverage Begins The following chart explains when coverage begins.

If you... Coverage generally begins...

Enroll during the annual enrollment period January 1 of the following year.

Are a new hire

PBI employee: The first day of the month after your hire date, if you are actively at work on that date.

Presort, Level One or Call Center employee: First of the month following 60 days after your hire date if you are actively at work on that date.

If you are rehired For all eligible employees: First of the month after rehire date if reemployed within 12 months. If rehired more than 12 months from termination date, new hire waiting period applies as discussed above.

Have a qualified change in status event The date of the qualifying event if you make the change within 30 days of the event. For more information, see Making Changes During the Year.

Have a change in employment status and become benefit-eligible

The date your status changed as long as you have satisfied the above requirements.

If you transfer from one participating Pitney Bowes business unit to another

The date your status changed. There wont be a break in your coverage as long as there are no gaps in your service with a participating Pitney Bowes business unit.

Have a child covered by a QMCSO The date specified on the court order.

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Situations Affecting Your Benefits If You Live in Massachusetts If you enroll in any medical option offered by Pitney Bowes, you must comply with the Massachusetts Health Care Reform Law (the "MA Law"). As of July 1, 2007, the MA Law requires that all Massachusetts residents age 18 and over (with some exceptions) obtain and maintain health insurance. This coverage requirement also applies if you work outside of Massachusetts but live in the State. Pitney Bowes complies with the MA Law by offering you Medical Plan coverage if you are a full-time employee residing in Massachusetts and permitting you to make before-tax contributions to a cafeteria (Flex) plan. If you decline to enroll in any of the medical options offered by Pitney Bowes, you must sign a waiver and indicate whether you have an alternative source of coverage.

When Youre Disabled or Not Actively at Work

If Youre On an Approved Leave of Absence If youre on an approved leave of absence, including leave under the Family Medical Act (FMLA), you may continue your medical coverage through the Flexible Benefits Program.

If your approved leave of absence is:

Active military service: your medical coverage for yourself and your family, including prescription drug and behavioral health care coverage, remains in effect for two years from the time the military leave begins, unless you elect to discontinue coverage. If you elect coverage, the cost of coverage at the active employee rate will be deducted from your differential compensation payments. If differential compensation is not paid to you or is not sufficient to pay the cost of coverage, youll be billed directly for the cost of coverage. For military leave longer than two years, you and your dependents will be offered the chance to continue coverage through COBRA. Gaining coverage because you become active in the military is considered a qualifying change in status event and allows you to drop your Pitney Bowes benefits coverage.

Any other approved leave: your medical coverage (which includes prescription drug and behavioral health care coverage) continues as long as you make the required contributions by the due date. Please note: If you are on a personal leave or FMLA (considered an unpaid leave of absence) for more than four weeks, you will be billed for coverage directly. Your benefits remain the same.

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FMLA Leave FMLA provides you with certain rights to a leave of absence and protects your job while youre on the approved leave (FMLA leave). If you are employed with Pitney Bowes for at least 12 months, with at least 1,250 hours of service during the 12-month period immediately before the beginning of the leave, you may be eligible for an FMLA leave of up to 12 work weeks:

For the birth or placement for adoption or foster care for your child and to care for him/her after the event;

To care for your spouse, son, daughter or parent who has a serious health condition; If you have a serious health condition (including pregnancy) that makes you unable

to perform your job; or

To address certain qualifying exigencies due to your spouse, son, daughter or parent participating in covered active duty (or being notified of an impending call or order to be on covered active duty) in the U.S. Armed Forces. Qualifying exigencies include arranging for alternative childcare, addressing certain financial and legal arrangements, and attending certain military events, counseling sessions and post-deployment reintegration briefings. Covered active duty includes certain military duty performed by members of reserve components (i.e., National Guard and Reserves) and members of regular components of the U.S. Armed Forces. Generally, covered active duty is limited to duty during deployment to a foreign country. In addition, if you are the spouse, son, daughter, parent or next of kin of a covered service member, you may be eligible for up to 26 weeks of leave during a single 12-month period to care for a covered service member with a serious injury or illness. Certain current and temporary disability retired list members (as well as veterans of the U.S. Armed Forces, including the National Guard and Reserves) may qualify as covered service members. To qualify as a covered service member, an individual must be undergoing medical treatment, recuperation or therapy, or must be on status, for a serious illness or injury incurred or aggravated in the line of duty on active duty. For a veteran, the individual must have been a member of the Armed Forces sometime within five years before the date on which the veteran undergoes the medical treatment, recuperation or therapy.

If Youre On Short-Term Disability (STD) Your current medical coverage (which includes behavioral health care and prescription drug coverage) and your payroll deductions for your contributions continue. If your period of STD extends over an annual enrollment period, youll have an opportunity to change your medical coverage.

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Youll be direct billed for the cost of your coverage if:

Your STD coverage ends before LTD benefits begin, You are on unpaid but approved STD, or The cost of coverage is more than the amount of your disability payment. Please note: Direct Bill Payments must be received by TowersWatson, the Pitney Bowes Flexible Benefits Administrator, by the due date shown on your monthly invoice or your coverage will be cancelled. Contact the Pitney Bowes Benefit Center at 1-888-469-7276 with any questions.

If Youre On Long-Term Disability (LTD) or Receiving Workers Compensation Benefits If youre on Long-Term Disability (LTD) or Workers Compensation, youre considered an inactive employee. However, youll still be able to choose the medical option that is right for you and your family. Options offered are dependent on whether you are eligible for Medicare. Please note: For disabilities beginning on or after March 1, 2003, inactive employment status may continue for two years. After two years of LTD or Workers Compensation status, your employment is terminated, and eligibility for medical, prescription drug and behavioral healthcare coverage ends. Disability or Workers Compensation benefits may continue.

If you are on inactive employment status and your period of LTD or Workers Compensation extends over an annual enrollment period, youll have an opportunity to change your coverage.

During annual enrollment while on inactive employment status, you may elect to keep or decrease your medical coverage. If you elect No Coverage, for medical, you cant change that election unless you have a qualified change in status event.

Once you are approved for Social Security income and Medicare becomes your primary coverage (you become Medicare-Prime), you will be offered a plan that supplements or coordinates with Medicare. You must also enroll in Medicare Parts A and B when you enroll in a Pitney Bowes complementary/supplemental option.

If you return to active employment with Pitney Bowes, you'll have the opportunity to elect new Flexible Benefit options, including a medical option, upon your return from LTD or Workers Compensation.

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How the Medical Plan Works The Health Fund PPO offers different coverage levels depending on whether you use an in-network (participating) or out-of-network (non-participating) provider (doctors, hospitals and healthcare facilities).

In-Network and Out-of-Network Providers Each time you seek medical care, you choose whether to use an in-network or out-of-network provider. When you use in-network providers:

Most preventive care services are free. You pay a percentage of the cost (coinsurance) for certain preventive prescription

drugs.

All other medical care and prescription drugs require you to pay coinsurance and a deductible.

For more information on deductibles and coinsurance, see Cost Sharing below.

You may be able to access UnitedHealthcare Premium network, which allows you to seek treatment from a Tier 1 designated doctor. These doctors have been recognized for providing quality and cost efficient care to their patients. They meet or exceed nationally recognized guidelines and are likely to recommend the right tests and treatments for a variety of conditions. Look for the Tier 1 designation on myuhc.com. When you use a Premium designated physician coinsurance on billed services will be lower.

If the network does not have a participating provider that can provide medically necessary services, UnitedHealthcare may authorize you to see an out-of-network provider, and cover the services at the in-network level. Also, if you receive services from an out-of-network doctor or other health care professional while being treated at an in-network hospital through no fault of your own (for example, the radiologist who reads your x-ray), UnitedHealthcare may approve payment at the in-network level.

Emergency room treatment for a true emergency (treatment for a sudden, unexpected and life-threatening illness or injury) is always paid at the in-network level of benefits.

Out-of-network benefits are paid based on maximum allowable charges. The maximum allowable charge is the most the Plan will pay for a specific service, supply or procedure. If an out-of-network provider charges more than the maximum allowable charge, the provider may require you to pay 100% of the excess amount (in addition to your deductible and coinsurance).

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Cost Sharing You and Pitney Bowes share in the cost of the medical care you receive. Some servicessuch as preventive careare provided at no cost to you. For most covered medical expenses, after the Plan pays its share of the expenses, you must pay any remaining costs. This includes any amounts limited or not covered by the Plan, as well as any amounts over the maximum allowable charges. Any additional out-of-pocket expenses incurred because you did not provide pre-notification will not count toward your deductible or out-of-pocket maximum.

Your deductible and out-of-pocket maximum varies by whether you choose the Health Fund option with a health reimbursement account (HRA) or a health savings account (HSA).

In-Network Out-of-Network Annual Deductible HRA: $1,600 you only

coverage; $3,200 all other coverage types

HSA: $1,500 you only coverage; $3,000 all other coverage types

HRA: $3,200 you only coverage; $6,400 all other coverage types

HSA: $3,000 you only coverage; $6,000 all other coverage types

Coinsurance 20%* after deductible 50% after deductible Out-of-Pocket Maximum HRA: $3,200 you only

coverage; $6,400 all other coverage types

HSA: $3,000 you only coverage; $6,000 all other coverage types

HRA: $6,400 you only coverage; $12,800 all other coverage types

HSA: $6,000 you only coverage; $12,000 all other coverage types

*Note that if you use a Tier 1 physician in the Premium network, the coinsurance that applies to his/her charges will be 10%, not 20%.

Annual Deductibles The annual medical deductible is the amount you must pay each calendar year before the Plan pays benefits for certain services. Services subject to the deductible are shown in the Covered Services section.

Individual Deductible: If you elect coverage for yourself only, you must meet an individual deductible. You meet your individual deductible when your covered medical and/or prescription drug expenses for the calendar year equal the deductible amount shown above.

Family Deductible: The family deductible amount shown in the Summary of Coverage can be met by any combination of covered medical and/or prescription drug expenses incurred by any family members. There is no individual amount per person.

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Note: the Health Fund PPO option requires you to pay the full cost for all non-preventive care up to your deductible amount per calendar year.

Its important to note that covered services cross-apply to your deductible. Out-of-network deductible expenses apply toward meeting the in-network deductible and in-network deductible expenses apply toward meeting the out-of-network deductible.

Coinsurance Once you meet the deductible, the Plan will pay a percentage of the allowable charge for most covered services (including non-preventive covered medical and prescription drug expenses). This percentage is known as coinsurance. The percentage the Plan will pay depends on the type of covered services you receive and whether you receive care from an in-network or out-of-network provider, and, if available, a Tier 1 designated Premium physician.

Annual Out-of-Pocket Maximum The annual out-of-pocket maximum is the maximum amount that you or your family will have to pay each calendar year for out-of-pocket medical and prescription drug expenses. Once you meet the applicable out-of-pocket maximum amount, the plan then pays 100% for all eligible medical and prescription drug expenses for the rest of the year.

Expenses that apply toward the out-of-pocket maximum are the deductible amounts and the coinsurance for covered medical and prescription drug expenses.

The following expenses do not apply to the out-of-pocket maximum:

Expenses over the fee schedule or maximum allowable charges. Expenses incurred for services or items excluded or not covered by this Plan. Expenses over Plan limitations. Penalties imposed because of failure to comply with pre-notification requirements. Cost Effective Care Provisions The Plan contains several provisions to help ensure you receive the most cost-effective care possible. These include case management, concurrent reviews and notification.

Case Management If you or one of your family members has a potentially complex medical condition, you may be eligible for case management. Through this program, UnitedHealthcare evaluates your current health care needs, the quality of care you are receiving, and the cost associated with your situation. After this evaluation, your case manager may recommend alternatives to your current course of treatment. These recommendations will be based on services that may reduce your costs, the help you may receive from

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friends or family, and the availability of community services. Other treatments and services may include a skilled nursing facility, specialized nursing or home care. The case manager will work with you, your doctor and other providers to coordinate and monitor services to meet your medical needs. UnitedHealthcare will determine whether you are eligible for the case management program.

Notification PLEASE READ THIS SECTION CAREFULLY. FAILURE TO FOLLOW THIS PROCESS MAY RESULT IN FINANCIAL PENALTIES OR A REDUCTION IN BENEFITS.

You must let UnitedHealthcare know before you receive certain types of care or are admitted to the hospital. This is called notification. If you are not sure if it applies, call the member services phone number on your ID card.

Certain services and surgery will always require notification. You or your provider must call UnitedHealthcare at the phone number on the back of your medical ID card. Please note: Network providers will generally notify UnitedHealthcare for you, but it is still up to you to make sure notification is handled before services are received.

Services that require Notification include, but are not limited to:

Inpatient admissions. External prosthetics. Infertility treatment. Outpatient imaging (MRI/MRA/CT scans). Outpatient surgery. Reconstructive procedures. Dental services for treatment of an accidental injury. Transplant procedures. Maternity care if the stay exceeds 48 hours for normal delivery or 96 hours for a

cesarean section.

Additionally, you must notify UnitedHealthcare for following services before you obtain them on an out-of-network basis:

Hospice care; Home health care;

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Durable medical equipment with a cumulative cost exceeding $1,000; Emergency health services if youre admitted to a non-network hospital; Private duty nursing; Skilled nursing facility; and Inpatient services at an out-of-network facility. How Your Benefits Are Affected The chart below illustrates how your benefits are affected if you dont notify the UnitedHealthcare before services are received.

If Notification Is: And: Then the Expenses Are:

Provided Your services are not covered

Not covered, but may be appealed. For more information, please refer to the Appealing Claims section.

Not provided Your services would have been covered if you notified the plan

If an Out-of-Network Provider is used, a patient penalty of $200 will apply to covered services that were authorized by the Health Plan post-service. Any admission not authorized will result in the claim being denied.

Not provided Your services would not have been covered even if you did notify UHC

Not covered, but may be appealed. For more information, please refer to the Appealing Claims section.

Note: Any additional out-of-pocket expenses incurred because you did not notify UHC will not count toward your deductible or out-of-pocket maximum.

Concurrent Review A concurrent review is a review of a notification that is done while you are hospitalized or receiving treatment. As a result of a concurrent review, the plan may approve additional benefits for ongoing care you may need.

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Health Fund Account When you elect the Health Fund PPO you have the option of using a Health Reimbursement Account (HRA) or opening a Health Savings Account (HSA) to help you pay for your qualified out-of-pocket health care expenses. And, if you open an HSA and fund it using payroll deductions, Pitney Bowes will contribute to your account.

When You Elect the Health Fund PPO with Health Reimbursement Account (HRA) When you receive health care services, the expenses will automatically be deducted from your HRA. Your HRA funds can be used for covered medical, behavioral health and prescription drug expenses. For example, if you go to your specialist for treatment of your heart condition, the cost of the office visit will be deducted from your HRA.

Your HRA is only funded by Pitney Bowes. You dont open up a bank account - the HRA funds are automatically used up to your HRA balance, when your claim is processed by UHC. The amount funded is determined by your coverage.

$500 if you only cover yourself. $1,000 if you cover a spouse/domestic partner and/or dependent children. With an HRA, you dont use any of your own money to pay for the deductible until you use up the amount that Pitney Bowes funds in the account. HRA funds are available on the first day your benefits are active.

Note: If you are hired during the year (e.g., July) you will not receive the full HRA amount. Contact the PB Benefits Center for the amount that will be funded in your HRA.

If there is money left over at the end of the year, it carries over (up to the out-of-pocket maximum) to the next year (as long as you are enrolled in the Health Fund PPO plan with the HRA option).

If you leave Pitney Bowes, you will lose any funds remaining in your HRA.

When You Elect the Health Fund PPO with Health Savings Account (HSA) Like an HRA, a Health Savings Account (HSA) helps pay for medical, behavioral health and prescription drug expenses.

With an HSA, you have choices on how to manage your money. You can use money in your HSA to pay for medical expenses, pay other out-of-pocket expenses (such as dental or vision care) or save for future health-related expenses such as COBRA coverage, retiree medical contributions and Long-Term Care insurance.

You and Pitney Bowes contribute to the HSA. Your contributions are made on a pre-tax basis, which lowers your taxable income (which lowers the amount of taxes you pay). Heres how the company match works. When you use payroll deductions, Pitney Bowes will match 50% of your contribution up to: $500 for you only coverage or $1,000 for all other coverage levels.

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Half of the company match will be funded after your first paycheck in January or your pay period following your enrollment as a new hire. The additional match will be funded in equal amounts over the next 11 pay periods or the remaining pay periods in the year if youre starting your funding after July 1. In the event a participant changes his or her funding election then the remaining funding will be based on actual election as of time of funding and, if the HSA is overfunded as of that date, the Company has the right to cease future funding to the HSA or reduce future funding amounts so that only the amount due the HSA is funded.

Note: You must contribute to your HSA via payroll deduction in order to receive the 50% match contributions from Pitney Bowes.

Heres how the HSA works:

The HSA is only available with the Health Fund PPO Plan. You must select this plan to be eligible for the HSA.

You own your HSA. It is a bank account that you contribute money into to cover health-related expenses. Interest is paid on your account and you may have investment choices. Like any other bank account, you may have to pay banking fees.

You can use the HSA account for vision and dental, current health care expenses or save funds. You dont lose your money if you do not use it by the end of the year.

Because an HSA is a bank account, you need to pick the bank. You have three choices:

The bank connected to the health plan you selected for your Health Fund PPO Plan (Optum Bank)

Bank of America A bank of your own (if you choose this option, Pitney Bowes will not match your

contributions)

If you use Bank of America or Optum Bank, your HSA will be funded by pre-tax contributions through your payroll deductions. Its automatic and you dont have to think about it.

If you prefer to set up your HSA at your own bank, you will need to fund it with your own after-tax dollars, which means you will get the tax savings when you file your federal income taxes.

You can also do bothhave automatic payroll deductions go into your HSA and make your own after-tax deposits. You just have to stay within your allowed maximum contribution.

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The annual maximum you can contribute to your HSA is:

$3,300 for you-only coverage $6,550 for all other coverage Age 55 or older can contribute an additional $1,000 per year The chart below lists the banks you can select for your HSA and compares their features. Note: Fees and earnings are effective January 1, 2014, but are subject to change whenever the Bank chooses.

HSA Banks Bank of America Optum

Web site http://www.bankofamerica.com/benefitslogin

myUHC.com

How you can use your funds

VISA debit card Online bill pay Online account transfer

MasterCard debit card Online bill pay Checks Online account transfer

Fees Box of 25 checks ATM transactions Non-sufficient funds

Not applicable Not applicable Not applicable

$10.00 $1.50+your banks fee $20.00

Account Earnings Note: Earnings are not guaranteed at these rates; the rates are subject to change at any time

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Covered Services The following sections describe services provided by the Plan. These services are covered as long as they are:

For off-the-job injuries and illnesses (Workers' Compensation covers job-related injuries and conditions),

Performed or approved by a licensed doctor. A doctor whose services these plans cover is an M.D. (medical doctor), D.O. (osteopath) or D.D.S. (dental surgeon). Other providers, such as Nurse Practitioners and Physician Assistants, may be covered for certain services, providing that a) the provider is properly licensed by his or her state, b) the service being billed is considered to be within the scope of the provider's license, and c) the service is covered by the benefit plan for the member that received the service,

For medical care that is medically necessary. In each section, you will find what is covered, what is not covered, and any pre-authorization requirements associated with specific covered services. The cost sharing descriptions indicate what you pay. For general limitations that apply across covered services, see General Limits and Exclusions.

Preventive Care In-Network Out-of-Network

No Cost to You 50% coinsurance

Whats Covered Office visit with your primary care physician for a preventive exam. Exams and certain lab tests and cancer screenings are covered as follows:

For children under age three, per recommended guidelines. For children between the ages of 3 and 19, one visit per calendar year. For adults age 19 and older, one visit per calendar year. Preventive immunizations, including, one flu shot per year in a physicians office or

outpatient setting.

Hearing examsone routine exam per calendar year.

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Vision examsone routine exam per calendar year with an in-network provider; when using an out-of-network provider, one exam every two years if under age 40 and one exam each calendar year if age 40 or older.

Preventive testing: PSA tests: one per year after age 50, or at any age if risk factors are present.

Mammograms: one baseline test before age 40, one per year after age 40.

Cervical cancer screening once every three years.

Beginning at age 50 (or sooner if considered high risk), one colonoscopy every 10 years or one sigmoidoscopy every five years. Coverage includes anesthesia, preparatory consultation with a specialist and preparatory kit covered under Prescription Drug plan.

Nutritional Counseling Medical education services provided by an appropriately licensed dietician or

health care professional in an individual session for covered persons with medical conditions that require a special diet (e.g. obesity, hypertension, diabetes, athero-sclerosis). 6 visits per condition are covered at no cost to you. The plan does not cover weight loss programs or treatments, even if prescribed or recommended by a physician or under medical supervisions

Preventive care for women also includes:

An annual well-women visit to determine what preventive services are appropriate and additional visits as necessary to help you get the care you need to be healthy.

A gestational diabetes screening if you are pregnant or at high risk of developing gestational diabetes.

A Human Papillomavirus (HPV) DNA test beginning at age 30 or older. An annual Sexually Transmitted Infection (STI) counseling visit. An annual HIV screening, and access to annual counseling on HIV. Coverage for all Food and Drug Administration-approved contraceptive methods,

sterilization procedures and patient education and counseling (this does not include abortifacient drugs).

Breastfeeding support, supplies and counseling for pregnant and postpartum women, including access to comprehensive lactation support and counseling from trained providers, as well as breastfeeding equipment (such as breast pumps and nursing related supplies).

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Interpersonal and domestic violence screening and counseling for all adolescent and adult women.

Out Patient Office Visits with a Primary Care Physician or Behavioral Health Provider

Health Fund HRA only In-Network Out-of-Network

Outpatient office visit $20 copay 50% after deductible

Outpatient office visit with a behavioral health provider

$20 copay 50% after deductible

Whats Covered Covered health services received in a primary care physicians office for the evaluation and treatment of an illness or injury. Benefits are provided regardless of whether the physicians office is free standing, located in a clinic, or located in a hospital.

Where available, Web consultations with a doctor are covered subject to the $20 office visit copay.

Primary care physicians include internists, general practitioners, family practitioners and pediatricians.

Limits and Exclusions Consultations by telephone, email and telemedicine are not covered.

Diagnostic Procedures

Advanced Radiological Imaging Notification is required.

Whats Covered Diagnostic testing (e.g., MRI, CAT, PET, ultrasound).

Colonoscopy/Sigmoidoscopy

Whats Covered Diagnostic services to detect or treat illness.

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Laboratory/X-ray Expenses

Whats Covered Charges directly connected with x-rays, fluoroscopy and laboratory tests for diagnostic purposes will be paid whether performed in a hospital, providers office, clinic or ambulatory care facility. Included are charges for such medical tests as basal metabolism, electrocardiographs and electroencephalograms. Services must be performed or authorized by a provider (M.D., D.O., D.D.S. or D.S.C.). Other services include non-preventive lab and independent lab.

Limits and Exclusions Routine x-rays taken by a doctor of dental surgery (D.D.S.) in connection with a surgery not covered under the medical plan are not payable.

Physician Services

Physician Visits

Whats Covered Covered health services received in a doctors office (whether free standing, located in a clinic, or located in a hospital) to evaluate and treat an illness or injury. Physician professional fees are also covered for medical services received in a hospital, skilled nursing facility, inpatient rehab facility or alternate facility.

Limits and Exclusions Consultations by telephone, email and telemedicine are not covered. Physician home visits are not covered. Acupuncture

Whats Covered Acupuncture for the treatment of chronic pain or nausea.

Limits and Exclusions The acupuncture benefit is limited to up to 20 visits (combined in-network and out-of-network).

Allergy Tests and Treatment

Whats Covered Allergy care which includes injections, antigens and serum in a providers office. Allergy testing

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Chiropractic Care

Whats Covered Benefits are payable for chiropractic services for spinal care, manipulations or adjustments for the treatment of neuromusculoskeletal conditions by a licensed Chiropractor (D.C.) or a Doctor of Osteopathy (D.O.) who participates in the American Chiropractic Network (ACN). Benefits (subject to additional cost-sharing) will also be provided for x-rays made during visits to a chiropractor when necessary for the diagnosis and analysis of neuromusculoskeletal conditions.

Limits and Exclusions Benefits will be paid for outpatient care, up to 20 visits per calendar year combined in- and out-of-network.

Foot Care

Whats Covered Treatment for persons with severe systemic disease or preventive foot care for diabetes and peripheral vascular disease.

Limits and Exclusions The benefit does not cover routine foot care, including the paring and removal of corns and calluses or trimming of nails unless associated with foot care for diabetes and peripheral disease.

Injections

Whats Covered Benefits provided for injections received in physicians office when no other health services are received.

See also Allergy Tests and Treatment and Preventive Care.

Nutritional Counseling

Whats Covered The Plan covers one-on-one medical education services provided by an appropriately licensed dietician or health care professional. Intensive behavioral dietary counseling for adult patients with hyperlipidemia, diabetes, obesity and other known risk factors for cardiovascular and dietrelated chronic disease may be covered under Preventive Care and not subject to cost-share or visit limit

Limits and Exclusions Visits for medical conditions not listed above are limited to six per year per condition. The Plan does not cover weight loss programs or treatments, even if prescribed or recommended by a physician or under medical supervision

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Convenience Care/Urgent Care/Emergency Care

Convenience Care Centers

Whats Covered Unscheduled treatment of non-emergency illness or injuries, routine biometric

screenings and certain immunizations (provided within scope of clinics license).

Convenience care clinics (also known as walk-in clinics) are free-standing health care facilities (such as those found at CVS, Target and Wal-Mart).

Urgent Care Centers

Whats Covered Benefits are provided for services received at an Urgent Care Center. When services to treat urgent health care needs are provided in a physician's office, benefits are available as described under Physician's Office Services earlier in this section.

Emergency Health Services An emergency is defined as a serious condition that arises suddenly and, in the judgment of a reasonable person, requires immediate care. If admitted to the hospital, ER notification must be made within 48 hours.

Whats Covered Medically necessary emergency ambulance transportation (including air) to the

nearest hospital where emergency health services can be performed or for medically necessary transport to the nearest facility following hospitalization.

Required treatment to stabilize or initiate treatment in an emergency. Limits and Exclusions The following services are not covered:

Emergency health services determined to be non-emergencies. Failure to provide ER notification with 48 hours of a hospital admission will result in

reduced benefits.

Charges for travel beyond a local area hospital that is adequately equipped to provide the necessary care.

Ambulance Service

Whats Covered Medically necessary emergency ambulance transportation to the nearest hospital is covered. Because it is an emergency, in-network benefits are payable.

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Limitation and Exclusions The following are not covered:

Non-emergency transfer by ambulance between two hospitals or between a hospital and an extended care/rehabilitative facility unless you use an in-network provider.

Charges for travel beyond a local area hospital that is adequately equipped to provide the necessary care.

Family Planning and Maternity Care

Family Planning Notification is required for infertility treatment.

Whats Covered The Plan covers:

Testing and treatment in connection with an underlying medical condition. Testing to determine infertility and/or the cause of. Treatment and/or procedures specifically designed to restore fertility (including

infertility medications, GIFT, ZIFT, assisted reproductive technology, artificial insemination and in vitro fertilization).

Vasectomies Tubal ligations are covered under Preventive Care at no cost to you with an in-

network provider.

Contraceptive devices (e.g., IUDs, diaphragms or Depo-Provera) provided in a physicians office are covered at no cost to you when you use an in-network provider.

Limits and Exclusions Fertility testing and treatment must be coordinated through a Center of Excellence, otherwise, no benefit will be payable.

There is a lifetime limit of $10,000 for all related services billed with an infertility diagnosis (i.e., x-ray or lab services billed by an independent facility).

The following are not covered:

Reversal of male or female voluntary sterilization procedures; Genetic screening; or

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Pre-implantation genetic screening. Maternity Care/Birthing Center Notification is required for hospital stays longer than 48 hours after a normal vaginal delivery or 96 hours after a cesarean section.

Whats Covered Maternity care is covered for pregnancies of female employees, wives or female domestic partners of employees and female dependents covered under the medical plan. The Plan covers expenses in connection with traditional hospital, care, birthing centers and midwife services, as well as prenatal visits.

Prenatal services covered include, but are not limited to, radiology services (e.g., ultrasounds) and high risk pre-natal services. Routine in patient care for newborns will be covered under the mothers deductible and coinsurance. A separate deductible and coinsurance will apply to non-routine newborn care.

In accordance with the Newborns and Mothers Health Protection Act, the Plan does not restrict benefits for any hospital stay in connection with childbirth for mother or newborn child to less than 48 hours after a normal vaginal delivery or less than 96 hours after a cesarean section. However, federal law does not prohibit the mothers or newborns provider from discharging the mother or newborn earlier than 48 or 96 hours (as applicable), as long as the provider has consulted with the mother.

Limits and Exclusions Providers must obtain authorization for a hospital stay longer than the 48- or 96-hour limit.

Abortions

Whats Covered Elective and non-elective procedures performed in a providers office, inpatient facility or outpatient facility.

Dental, Hearing and Vision Care

Dental Care

Whats Covered Restorative dental services received from a Doctor of Dental Surgery, "D.D.S." or

Doctor of Medical Dentistry, "D.M.D." for:

Treatment of accidental injuries.

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Treatment provided under the direction of a physician: Diagnostic and surgical treatment of conditions affecting the temporomandibular

joint (TMJ).

Diagnostic or surgical treatment required as a result of accident, trauma, congenital defect, developmental defect, or pathology.

Limits and Exclusions Dental damage that occurs as a result of normal activities of daily living or

extraordinary use of teeth is not considered an "accident". Benefits are not available for repairs to teeth that are injured as a result of such activities.

Dental treatment of the teeth, gums or structures directly supporting the teeth, including dental x-rays, examinations, repairs, orthodontics, periodontics, casts, implants, splints and services for dental malocclusion for any condition other than charges for services due to accidental injury to teeth.

Dental services for final treatment to repair the damage must be started within three months of the accident and completed within 12 months of the accident.

Appliances and services that are dental in nature are excluded. Dental implants for any condition, except in the case of damage to implants as a

result of an injury.

Extraction and/or treatment of wisdom teeth. Hearing Care

Whats Covered Outpatient visits for the treatment of hearing loss. Cochlear implants when there is severe to profound bilateral sensorineural hearing

loss and severely inability to understand speech.

Limits and Exclusions The following are not covered:

Hearing aids (any device that amplifies sound), including but not limited to semi-implantable hearing devices;

Audiant bone conductors; and

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Bone Anchored Hearing Aids (BAHAs). Cochlear implants not pre-authorized. See also Preventive Care.

Vision Care

Whats Covered Treatment by a physician to diagnosis and treat illnesses or injuries to your eyes. Orthoptic therapy. Refer to Preventive Care for other covered vision services.

Limits and Exclusions The following are not covered:

Eyeglass lenses and frames and contact lenses (except for the first pair of contact lenses for treatment of keratoconus or post cataract surgery).

Eye exercises and surgical treatment for the correction of a refractive error, including radial keratotomy.

Mental Health and Substance Abuse

Mental Health and Substance Abuse Behavioral health care is administered by United Behavioral Health (UnitedHealthcare). You must call and notify United Behavioral Health (UBH) before you receive out-of-network inpatient mental health treatment. UBH will coordinate your inpatient care (whether in- or out-of-network) and your in-network outpatient care. The UBH phone number appears on your UnitedHealthcare ID card.

Whats Covered The plan covers both inpatient and outpatient treatment for mental health and substance abuse. Its important to remember that these benefits are subject to your medical deductible and out-of-pocket limits.

You may receive care from any:

Licensed clinical psychologist, Hospital or treatment facility licensed by the state agency responsible for licensing

mental health and substance abuse treatment facilities in the state,

Licensed psychiatrist (M.D.),

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Licensed psychiatric nurse (R.N. or A.R.N.P.), or Licensed psychiatric professional at the masters level or above. Covered services include:

Outpatient individual, family and group therapy by appropriately licensed providers. Medication evaluation and management. Assessment for a variety of mental health and substance abuse conditions (please

note that the Plan does not cover testing for learning and developmental disabilities).

Psychological testing. Outpatient ECT. Outpatient detoxification. Inpatient detoxification and substance abuse rehabilitation. Inpatient, partial hospital, residential and intensive outpatient services for mental

health and substance abuse conditions.

Treatment of: eating disorders.

attention deficit/hyperactivity disorder (ADD/ADHD).

anxiety disorders (e.g., post-traumatic stress syndrome, social anxiety).

impulse control and addiction.

mood disorders (e.g., depression or bipolar disorder).

psychotic disorders.

In addition, the program covers the following medically necessary substance abuse services in an approved substance abuse treatment facility (one that treats chronic alcoholism and/or drug abuse and that is licensed and regulated by the appropriate governmental agency in its location):

Treatment for alcoholism. Other types of substance abuse treatment at an approved licensed treatment facility

or hospital.

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Prescription drugs in connection with your physicians specific treatment plan. Services of a physician and licensed therapist. Emergency Mental Health or Substance Abuse Treatment If you are hospitalized in an emergency for mental health or substance abuse treatment and you are unable to call UBH to notify them of your care, then you, your physician, a family member or a friend must call UBH within 48 hours of the admission. United Behavioral Health will determine whether the plan will cover your hospital stay.

If you are admitted to a non-network hospital, you may be asked to transfer to a network hospital once your condition stabilizes. There may be lower payment under the plan if you choose to remain in a non-network hospital after it has been determined clinically appropriate for you to transfer to a network facility.

Limits and Exclusions The program does not cover the following services:

Services determined to be not medically necessary. Group home. Halfway house. Psychological testing, except on an exception basis. Home care. Prometa treatment. Services performed in connection with conditions not classified in the current edition

of the Diagnostic and Statistical Manual of the American Psychiatric Association.

Services or supplies for the diagnosis or treatment of mental illness , alcoholism or substance use disorders that, in UHCs reasonable judgment, are:

not consistent with generally accepted standards of medical practice for the treatment of such conditions;

not consistent with services backed by credible research soundly demonstrating that the services or supplies will have a measurable and beneficial health outcome, and therefore considered experimental;

not consistent with UHCs level of care guidelines or best practices as modified from time to time; or

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not clinically appropriate for the patients mental illness, substance use disorder or condition based on generally accepted standards of medical practice and benchmarks.

Services as treatments for V-code conditions as listed within the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association.

Services as treatment for a primary diagnosis of insomnia, other sleep disorders, sexual dysfunction disorders, feeding disorders, neurological disorders and other disorders with a known physical basis.

Treatments for the primary diagnoses of learning disabilities, conduct and impulse control disorders, personality disorders and, paraphilias (sexual behavior that is considered deviant or abnormal).

Educational/behavioral services that are focused on primarily building skills and capabilities in communication, social interaction and learning.

Tuition for or services that are school-based for children and adolescents under the Individuals with Disabilities Education Act.

Learning, motor skills and primary communication disorders as defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association.

Mental retardation as a primary diagnosis defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association.

Methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol), Cyclazocine, or their equivalents for drug addiction.

Autism and Childhood Development Disorders Childhood developmental disorders include:

Autism disorder Childhood disintegrative disorder Aspergers disorder Retts syndrome Pervasive development disorder

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Whats Covered Benefits include the following services provided on either an inpatient or outpatient basis:

Initial diagnostic evaluation and assessment. Treatment planning. Referral services Medication management Individual and group therapy as well as crisis intervention Under the medical plan, up to 100 days of care combined for outpatient speech,

physical and/or occupational therapy (combined in or out-of-network), up to age 18.

Limits and Exclusions The plan does not cover intensive behavioral therapies such as applied behavioral

analysis for Autism Spectrum Disorders, and any treatments or other specialized services designed for Autism Spectrum Disorder that are not backed by credible research demonstrating that the services or supplies have a measurable and beneficial health outcome and therefore considered experimental or investigational or unproven.

Inpatient Hospital Care and Surgery

Hospital Confinement/Inpatient Hospital Expenses Notification is required.

Whats Covered Benefits will be paid for expenses resulting from a hospital confinement, including care in an Intensive Care Unit, with no copay. Benefits apply to:

Semiprivate room and board. Intensive, cardiac, contagious or isolation care. Administration of anesthetics, laboratory work and x-rays. If you are confined in an

in-network hospital but these providers do not participate with UnitedHealthcare, their services will be covered at the in-network benefits.

Use of operating rooms, medicines, dressings, splints, drugs and other necessary services and supplies.

Charges made by hospital-approved medical employees, technicians and physicians for the use of hospital equipment.

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Charges by non-hospital employees for use of hospital equipment when service is not generally available by hospital employees.

Limits and Exclusions The following are not covered:

Private hospital rooms; Personal or comfort care items such as personal care kits provided on admission to

a hospital;

Television; Telephone; Newborn infant photographs; Complimentary meals; Birth announcements; and Other articles that are not for the specific treatment of illness or injury. Surgical Procedures

Whats Covered Benefits are payable for necessary surgeries, including surgeon and anesthesiology

services whether performed in a hospital, ambulatory surgical center, outpatient surgical center or a providers office. Out-of-network services/procedures are subject to the notification rules as well.

Services of a physician assisting the operating physician with a surgical procedure as well as pre- and post-operative care.

Second and third surgical opinions are not mandatory, but are a covered expense in connection with a non-emergency surgical procedure.

Limits and Exclusions General anesthesia is a covered expense when administered by a doctor or a registered nurse anesthetist for covered surgeries. However, benefits do not apply for charges for the administration of local infiltration anesthetics or for anesthetics administered by the operating surgeon, the assistant surgeon or any person paid by the hospital or other institution.

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The following are not covered:

Rhinoplasty; Blepharoplasty; Surgical services, initial and repeat, intended for the treatment or control of obesity

(including clinically severe (morbid) obesity) even if prescribed or recommended by a physician;

Transsexual surgery, including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery;

Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the health plans opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.

Cosmetic surgery. Breast Reconstruction/Reduction Notification is required.

Whats Covered Breast reconstruction and/or reduction that is not cosmetic in nature.

Limits and Exclusions Breast reduction for cosmetic reasons is not covered. Pre-Authorization is required. In compliance with the Womens Health Care and Cancer Rights Act of 1998, the Plan covers reconstructive breast surgery, after consultation with a physician, according to the same deductibles, coinsurance and out-of-pocket maximum provisions that apply to other Plan services. The coverage includes:

Prosthesis and treatment of physical complications at all stages of the mastectomy, including lymph edemas,

Reconstruction of the breast on which the mastectomy was performed, and Surgery and reconstruction of the other breast to produce a symmetrical

appearance.

Organ Transplants - Centers of Excellence Notification is required.

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Whats Covered A person in need of a medically appropriate, non-experimental organ transplant will be required to use a Center of Excellence. Centers of Excellence are facilities that specialize in organ transplants. There is no coverage out-of-network.

UnitedHealthcare will coordinate treatment with a case manager. The case manager will coordinate admission requirements, specialty referrals, hospital billing, transport and lodging of the patient and one adult (or two adults if the patient is a minor under age 18).

Limits and Exclusions Coverage is only provided if transplants are performed in a Center of Excellence.

Transportation and travel expenses, excluding meals, for the patient and a companion (if the patient is a minor child, two companions) will be covered at a per diem rate of $50 for one person and $100 for two people for lodging, up to $10,000.

The Plan does not cover:

Travel within a 50-mile radius of the patients home. Fees associated with the collection or donation of blood or blood products, except

for autologous donation in anticipation of scheduled services where in the health plans opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.

Therapeutic Treatment

Chemotherapy

Whats Covered The Plan pays benefits for therapeutic treatment received on an inpatient or outpatient basis at a hospital or alternate facility or physicians office. If the office visit is also billed, benefits provided as described in the Physician Visit section for office visit benefits.

Dialysis

Whats Covered The Plan pays benefits for dialysis treatment received on an outpatient basis at a hospital or alternate facility.

Radiation Therapy

Whats Covered Charges for x-ray, radium and radioactive isotopic therapy are covered wherever performed.

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Services Instead of Hospitalization

Home Health Care Notification is required for out-of-network home health care, including private duty nursing services.

Whats Covered Home health care benefits are used in place of benefits for hospital or nursing home confinement. The services must be provided by a home health care agency and all services must be recommended by a physician in lieu of inpatient confinement.

Covered services include professional services and medical supplies as described below.

Nursing care provided as part of a home health care program when provided by a licensed nurse (R.N., L.P.N, or L.V.N.).

Home health care aide. Physical, occupational, respiratory and speech therapy. Medical social services by a licensed social worker (provided the services are part of

the treatment).

Limits and Exclusions

In-network and out-of-network visits are combined and are limited to 100 days per calendar year, including Private Duty Nursing Care.

Nursing care provided as part of home health care is limited to 16 hours a day; with each visit limited to four hours or less. Private Duty Nursing expenses include care provided by an R.N. or L.P.N. if the persons condition requires skilled nursing care and visiting nursing care is not enough. A private duty nursing shift is limited to eight hours.

The plan does not cover custodial care such as assistance with the activities of daily living, including but not limited to:

Eating, Bathing, Dressing, Other custodial services or self-care activities, Homemaker services and

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Services primarily for rest, domiciliary or convalescent care. Hospice Care Notification is required if care is received out-of-network.

Whats Covered Care for terminally ill patients furnished by any formal hospice program if the care is recommended by the attending physician and included in the patient's treatment plan. Notification is required out-of-network.

Benefits include:

Inpatient and outpatient care for acute intervention, medical crisis, or pain management.

Bereavement support (short-term grief counseling) for the patient's immediate family within three months following the patient's death.

Covered services and supplies include nursing care, home health care services, respiratory and inhalation therapy, medical social services, individual and family counseling, and respite care.

Skilled Nursing Facilities Notification is required if care is received out-of-network.

Whats Covered Post-hospital convalescence benefits are available for care by a covered approved convalescent extended care or rehabilitation facility.

The services must be approved in writing by the attending doctor. The doctor must certify that the care is medically necessary and that, in the absence of extended care facility confinement, you would require inpatient hospital care.

Limits and Exclusions Benefits will be paid for up to 100 days per calendar year for room and board expenses and necessary services and supplies.

Benefits are not available for custodial, domiciliary or maintenance care (including administration of enteral feeds) which, even if it is ordered by a doctor, is primarily for the purpose of meeting the patients personal needs or maintaining a level of function, as opposed to improving that function to an extent that might allow for a more independent existence.

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Rehabilitation Services

Occupational Therapy/Physical Therapy/Speech Therapy

Whats Covered Therapy or treatment intended to primarily improve a general physical condition.

Limits and Exclusions Coverage applies to charges for up to 40 visits per calendar year/per acute episode

(100 visits for childhood developmental conditions, up to age 18) combined, in- and out-of-network and combined for occupational, physical and speech therapy. Additional visits are available if medically appropriate and approved by UnitedHealthcare.

The Plan does not cover any type of therapy, service of supply for the treatment of a condition which ceases to be therapeutic and, is instead, administered to maintain a level of functioning or to prevent a medical problem from occurring or reoccurring.

Cardiac Rehabilitation

Whats Covered Outpatient cardiac rehab (Phase I and Phase II).

Limits and Exclusions Outpatient Cardiac Rehabilitation is limited to 36 visits (combined in and out-of-network) per condition per calendar year are covered if medically necessary.

Pulmonary Rehabilitation

Whats Covered Short-term pulmonary rehabilitation therapy.

Equipment and Supplies

Diabetic Medical Supplies and Equipment

Whats Covered Blood glucose monitors (including those meant to be used by blind individuals),

insulin infusion pumps and accessories, insulin infusion devices and podiatric appliances to prevent complications associated with diabetes.

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Limits and Exclusions Insulin supplies/services provided under prescription drug benefits. Test strips for blood glucose monitors, visual reading and urine test strips, lancets

and lancet devices, insulin and insulin analogs, injection aids, syringes, prescription and non-prescription oral agents for controlling blood sugar levels, glucagons emergency kits and alcohol swabs (covered under Prescription Drug benefits).

Disposable Medical Supplies

Whats Covered Consumable medical supplies limited to supplies used by health care professionals

in providing home health care services or used in conjunction with authorized durable medical equipment.

Urological, orthopedic, ostomy bags, supplies and dressings and Enteral nutrition when the sole source and inborn error of metabolism. Limits and Exclusions Prescribed or non-prescribed medical supplies and disposable supplies. Examples

include: elastic stockings, ace bandages, gauze and dressings, and syringes.

Devices used specifically as safety items or to improve performance in sports-related activities.

Medical supplies, whether or not prescribed. Tubings, nasal cannulas, connectors and masks not used in connection with durable

medical equipment.

Orthotic appliances. Cranial banding. Deodorants, filters, lubricants, tape, appliance cleaners, adhesive, remover or other

items.

Durable Medical Equipment and Supplies Notification is required for equipment costing $1,000 or more when acquired from an out-of-network provider.

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Whats Covered Purchase or rental of necessary medical equipment, including oxygen and

equipment for its administration, surgical dressings, casts, splints, trusses, braces, crutches, wheelchairs, hospital beds, iron lungs, hypodermic needles, syringes, certain support garments and similar items if their use is certified by the attending physician as medically necessary and, for purchases, the cost to rent the equipment for the period of use is more than the cost to purchase.

Diabetic footwear. Foot orthotics (except over-the-counter orthotics). Limits and Exclusions Consumable medical supplies other than ostomy supplies and urinary catheters are not covered. Arch supports are not covered.

Prosthetic Devices Pre-Notification is required for external prosthetics.

Whats Covered The Plan covers the initial purchase and fitting of prosthetic devices.

Limits and Exclusions Replacement is only covered in cases of anatomical growth.

A separate $500/cy benefit is available for the purchase of a wig when hair loss is due to injury, disease or treatment of a disease. The following are not covered:

Wigs for male pattern baldness.

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General Limits and Exclusions The Medical Plan does not cover the following services

Alternative Treatments The following services are excluded from coverage regardless of clinical indications:

acupressure; dance therapy, movement therapy; applied kinesiology; rolfing and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions.

Services Provided under Another Plan Care for health conditions that are required by state or local law to be treated in a

public facility.

Care required by state or federal law to be supplied by a public school system or school district.

Care for military service disabilities treatable through governmental services if you are legally entitled to such treatment and facilities are reasonably available.

Services, supplies or care for an injury or illness for which other non-group insurance coverage (except individual insurance policies) pay benefits, such as automobile no fault or medical payment insurance. If benefits are paid by the plan in this case, the plan reserves the right to recover payment, as described in the Subrogation section of this SPD.

All Other Exclusions Treatment of an illness or injury, which is due to war, declared or undeclared. Charges for which you are not obligated to pay or for which you are not billed or

would not have been billed except that you were covered by this Plan.

Any services and supplies for or in connection with experimental, investigational or unproven services. Experimental, investigational and unproven services are medical, surgical, diagnostic, psychiatric, substance abuse or other health care technologies, supplies, treatments, procedures, drug therapies or devices that are determined by your health plan to be:

Not demonstrated, through existing peer-reviewed, evidence-based scientific literature to be safe and effective for treating or dia