Trek 2011 Healthcare Plan Summary

7/30/2019 Trek 2011 Healthcare Plan Summary

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DISCLAIMER OF CLAIMS ADMINISTRATOR

We have prepared this document for your review and consideration; however, we are not legalcounsel, nor are we in the business of practicing law. As your plans fiduciaries and/or trustees,

you are fully responsible for all legal issues that concern the plan. If you are not an expert in thisarea, we urge you to hire an attorney to help you review this plan.


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BY THIS AGREEMENT, Trek Bicycle Corporation Employee Health Care Plan is hereby adopted asshown.

IN WITNESS WHEREOF, this instrument is executed for Trek Bicycle Corporation on or as of the dayand year first below written.

By ____________________________________Trek Bicycle Corporation

Date ___________________________________

Witness ________________________________

Date ________________________________


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SUMMARY PLAN DESCRIPTION

Trek Bicycle Corporation

EMPLOYEE HEALTH CARE PLAN

This booklet is the Summary Plan Description. Its purpose is to summarize the provisions of the Plan that

provide and/or affect payment or reimbursement. The Summary Plan Description supersedes any and allSummary Plan Descriptions issued to the Covered Person by Trek Bicycle Corporation.

The Plan is funded by Trek Bicycle Corporation and employee contributions, if required. The benefits andprincipal provisions of the group plan are described in this booklet. They are effective only if the CoveredPerson(s) are eligible for the coverage, become covered, and remain covered in accordance with theprovisions of the group plan.

The purpose of providing a comprehensive medical plan is to protect the Covered Persons from seriousfinancial loss resulting from necessary medical care. However, we must recognize and deal withescalating costs. Being fully informed about the specific provisions of the Plan will help both the CoveredPerson and the company maintain reasonable rates in the future. We have prepared the following pages as

a general guide for Covered Persons to become "good consumers" of health care. It will take a joint effortbetween eligible providers, Covered Persons and us, the company, to make our Plan work, both now andin future years.

All health benefits described herein are being provided and maintained for the Covered Persons and thecovered dependents by Trek Bicycle Corporation, hereinafter referred to as the "Company." Auxiant willprocess all benefit payments.

Please refer to the address on the ID card to determine where to send claims.


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TABLE OF CONTENTS

SECTION PAGE

WOMENS HEALTH AND CANCER RIGHTS ACT NOTICE 3PLAN DESCRIPTION 4

GRANDFATHERED PLAN NOTICE 7BENEFIT OVERVIEW 8SCHEDULE OF BENEFITS 11

Medical Schedule of Benefits 11Prescription Drug Schedule of Benefits 30

ELIGIBILITY FOR COVERAGE 33Employee Eligibility 33Employee Effective Date 33Dependent Eligibility 33Dependent Effective Date 35Timely Enrollment 36Late Enrollment 36

Special Enrollment 36Open Enrollment 38

PRE-EXISTING CONDITIONS 40CARE COORDINATION PROCESS 42MEDICAL EXPENSE BENEFITS 48

The Deductible 48Family Deductible Feature 48Usual and Customary Charges 48Medical Eligible Expenses 49

GENERAL LIMITATIONS 60PRESCRIPTION DRUG EXPENSE BENEFIT 67TERMINATION OF COVERAGE 70

Employee Termination 70Dependent Termination 70

EXTENSION OF BENEFITS 72Disability/Lay Off/Leave of Absence 72Family and Medical Leave Act Provision 72Uniformed Services Employment and Reemployment Rights Act (USERRA) 72COBRA Extension of Benefits 73

COORDINATION OF BENEFITS 80SUBROGATION 84DEFINITIONS 88RIGHTS UNDER ERISA 104GENERAL PROVISIONS 105


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WOMENS HEALTH AND CANCER RIGHTS ACT NOTICE

MEMORANDUM

TO: ALL HEALTH PLAN PARTICIPANTS

FROM: TREK BICYCLE CORPORATION AND AUXIANT

SUBJECT: WOMENS HEALTH AND CANCER RIGHTS ACT OF 1998

DATE: JANUARY 1, 2011

The Womens Health and Cancer Rights Act of 1998 requires Trek Bicycle Corporation to notify

you, as a participant or beneficiary of the Trek Bicycle Corporation health plan, of your rightsrelated to benefits provided through the plan in connection with a mastectomy. You as aparticipant or beneficiary have rights to coverage to be provided in a manner determined inconsultation with your attending physician for:

1. All stages of reconstruction of the breast on which the mastectomy was performed;2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and3. Prostheses and treatment of physical complications of the mastectomy, including

lymphedema.

Items 1. and 2. above will be payable under the inpatient surgery benefit, and item 3. will bepayable under the prosthetic benefit. For further details on deductible and coinsurance for thesebenefits, please refer to your Summary Plan Description.

Keep this notice for your records and call the plan administrator, Auxiant, at (800) 279-6779 formore information.


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PLAN DESCRIPTION

Purpose

The Plan Document details the benefits, rights, and privileges of Covered Persons (as later defined), in afund established by Trek Bicycle Corporation and referred to as the "Plan." The Plan Document explainsthe times when the Plan will pay or reimburse all or a portion of Covered Expenses.

Effective Date The effective date of the Plan is January 1, 2011.

Claims Administrator The Claims Administrator of the Plan isAuxiant.

Name of Plan Trek Bicycle Corporation Employee Health CarePlan

Name and Address of Plan Administrator Trek Bicycle Corporation801 West Madison Street

Waterloo, WI 53594(920) 478-2191

Name and Address of Claims Administrator Auxiant2970 Chapel Valley RoadSuite 203Madison, WI 53711(800) 279-6772

Employer I.D. Number 39-1237359

Plan Number 501

Type of Benefit Provided Medical and Prescription Drug ExpenseCoverage

Agent for Legal Service Trek Bicycle Corporation

Funding of the Plan Trek Bicycle Corporation and EmployeeContributions

Medium for Providing Benefits The benefits are administered in accordancewith the Plan Document by the ClaimsAdministrator.

Fiscal Year of the Plan Begins January 1st and ends December 31st


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Named Fiduciary and Plan AdministratorThe Named Fiduciary and Plan Administrator is Trek Bicycle Corporation, who will have the authority tocontrol and manage the operation and administration of the Plan. The Plan Administrator (or similardecision-making body) has the sole authority and discretion to: establish the terms of the Plan; determineany and all questions in relation to the administration, interpretation or operation of the Plan, including,but not limited to, eligibility under the Plan, the terms and provisions of the Plan, and the meaning of any

alleged vague or ambiguous term or provision; determine payment of benefits or claims under the Plan;and to decide any and all other matters arising under the Plan. The Plan Administrator has the final anddiscretionary authority to determine the Usual & Customary Fee.

Contributions to the PlanThe amount of contributions to the Plan is to be made on the following basis:

Contributions to the Plan are made by the Employer, which include Employee and Dependentcontributions. The Employer reserves the right to increase or decrease Employee or Dependentcontributions requirements from time to time. Notwithstanding any other provision of the Plan, theEmployer's obligation to pay claims under the terms of the Plan will be limited to its obligation to makecontributions to the Plan. Payment of claims in accordance with these procedures will discharge

completely the Employer's obligation with respect to such payments. In the event that the Employerterminates the Plan, the Employer and Covered Employees will have no further obligation to makeadditional contributions to the Plan as of the effective date of termination of the Plan.

Plan Modification and AmendmentsSubject to any negotiated agreements, the Employer may modify, amend, or discontinue the Plan withoutthe consent of or notice to Employees. Any changes made shall be binding on each Employee and on anyother Covered Persons. This right to make amendments shall extend to amending the coverage (if any)granted to retirees covered under the Plan, including the right to terminate such coverage (if any) entirely.

Termination of PlanThe Employer reserves the right at any time to terminate the Plan. The termination must be in writing.

All previous contributions by the Employer will be used to pay benefits under the provisions of this Planfor claims arising before termination, or will be used to provide similar health benefits to CoveredEmployees, until all contributions are exhausted.

Plan is not a ContractThe Plan Document constitutes the entire Plan. The Plan will not be deemed to constitute a contract ofemployment, to give any Employee of the Employer the right to be retained in the service of theEmployer, or to interfere with the right of the Employer to discharge or otherwise terminate theemployment of any Employee.

Claim ProcedureIn accordance with Section 503 of ERISA, the Employer will provide adequate notice in writing to any

Covered Employees whose claim for benefits under this Plan has been denied, setting forth the specificreasons for such denial and written in a manner calculated to be understood by the Employee. Further, theEmployer will afford a reasonable opportunity to any Employee, whose claim for benefits has beendenied, for a full and fair review of the decision denying the claim by the person designated by theEmployer for that purpose.

Protection against CreditorsBenefit payments under this Plan are not subject in any way to alienation, sale, transfer, pledge,attachment, garnishment, execution, or encumbrance of any kind. Any attempt to sell, transfer, garnish, or


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otherwise attach benefit payments under the plan in violation of this restriction will be void. If theEmployer discovers an attempt has been made to attach, garnish, or otherwise improperly assign or sell abenefit payment in violation of this section that would be due to a current or former Covered Employee,the Employer reserves the right to terminate the interest of that individual in the payment, and insteadapply that payment to or for the benefit of the Covered Employee, dependents or spouse as the Employermay otherwise decide. The application of the benefit payment in this manner will completely discharge all

liability for such benefit payment.

Indemnification of EmployeesExcept as otherwise provided in ERISA, no director, officer, or Employee of the Employer or of theClaims Administrator will incur any personal liability for the breach of any responsibility, obligation, orduty in connection with any act or omission done in good faith in the administration or management ofthe Plan, and will be indemnified and held harmless by the Employer from and against any such personalliability, including all expenses reasonably incurred in his defense if the Employer fails to provide suchdefense. The Employer and the Plan may individually obtain fiduciary liability coverage consistent withapplicable law.

National Correct Coding Initiative

Where not otherwise specified, this Plan follows National Correct Coding Initiative (NCCI) for coding,modifiers, bundling/unbundling, and payment parameters. Other guidelines may be applicable whereNCCI is silent. The Plan Administrator has full discretionary authority to select guidelines and/or vendorsto assist in determinations.


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GRANDFATHERED PLAN NOTICE

This Plan Sponsor believes this Plan is a grandfathered health plan under the Patient Protection andAffordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, agrandfathered health plan can preserve certain basic health coverage that was already in effect when thatlaw was enacted. Being a grandfathered health plan means that your Plan may not include certain

consumer protections of the Affordable Care Act that apply to other plans, for example, the requirementfor the provision of preventive health services without any cost sharing. However, grandfathered healthplans must comply with certain other consumer protections in the Affordable Care Act, for example, theelimination of lifetime limits on benefits.

Questions regarding which protections apply and which protections do not apply to a grandfathered healthplan and what might cause a plan to change from grandfathered health plan status can be directed to theplan administrator. You may also contact the Employee Benefits Security Administration, U.S.Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a tablesummarizing which protections do and do not apply to grandfathered health plans.


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Note: The following section is an overview of the Plan.

BENEFIT OVERVIEW

FOR

Trek Bicycle Corporation

Eligibility Provisions

The Employee should notify the employer of eligibility changes (i.e., total disability, retirement,

Medicare eligibility, change in Dependent status birth, marriage, divorce, etc.) as soon as

possible.

EFFECTIVE DATE OF PLAN January 1, 2011

ELIGIBLE CLASS All individuals who work for the Employer forat least 30 hours per week on a regular basis.Eligible employees also include the owner(s) ofTrek Bicycle Corporation and partner(s) in TrekBicycle Corporation. Leased employees are noteligible under the Plan.

Trek Bicycle may enter into a written contractwith an independent contractor that includesmedical coverage under the Plan during the termof the written contract, subject to theindependent contractor paying the full cost of

coverage.

EMPLOYEE EFFECTIVE DATE An individual will be eligible on the first daythat he/she is a Full Time, Active Employee ofthe Employer or a Part Time Active employeewho normally works 30 hours per week for anaverage of 48 weeks per year and is on theregular payroll of the Employer for that work.

CONTRIBUTION The Plan may be evaluated from time to time todetermine the amount of Employee contribution

(if any) required.

* Please see theEligibility for Coverage section for further details.


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Hospital Pre-Admission Certification

Continued Stay Review

MANAGED CARE The Plan requires that all non-emergencyInpatient hospitalizations be pre-certified by theReview Organization 48 hours prior to the

hospitalization; all emergency Inpatienthospitalizations must be reported within 48hours of admission. If an in-hospital stay is notpre-certified by the Review Organization,benefits related to the hospitalization will bereduced by $250 off the facility charge forInpatient Admissions and Skilled NursingFacility Admissions. (The penalty does notapply to the Annual Deductible or Out-of-PocketMaximum.)

The following services require pre-certification:

Inpatient and Skilled Nursing FacilityAdmissions

Outpatient Surgeries MRI/MRA and PET scans Oncology Care and Services

(chemotherapy and radiation therapy)

Home Health Care Hospice Care Durable Medical Equipment all rentals

and any purchase over $500

Organ, Tissue, and Bone MarrowTransplants

Dialysis Occupational, Physical and Speech

Therapy

*Please refer to the Care Coordination Process section for further details.


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PLAN LIMITATIONSANDMAXIMUMS OVERVIEWNegotiated Fee or Usual and Customary All charges are subject to either the

Negotiated Fee (if the Provider is a Network

Provider) or the Usual and Customary (U&C)fee for the area in which the service or supplyis received.

Hospital Room andBoard Limitation Semi-private rateIntensive Care Unit Limitation ICU rate

Skilled Nursing Facility Room andBoard Semi-private rateLimitation

Maximum Benefit for all Medical $1,000,000 per Plan Year

Expenses (Includes all other annual maximums)

Maximum Benefit for TMJ $1,250 per Calendar Year

(Temporomandibular Joint Disorder)

Maximum Benefit for Skilled Nursing Facility 45 days per Calendar Year

Maximum Benefit for Home Health Care 50 visits per Calendar Year

Maximum Benefit for Chiropractic Care 24 visits per Calendar year

Maximum Benefit for Organ Transplant Meals, $10,000 per transplant

Lodging & Travel Expenses


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EPO Benefit Plan Option

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NETWORK PROVIDERS

% of Network negotiated feeNON-NETWORK

PROVIDERS

% of Usual & Customary

Allergy Testing Office 100% deductible waived Not covered

Allergy Testing

Inpatient and Outpatient

100% deductible waived Not covered

Ambulance Service 100% deductible waived Not covered

If it is a valid emergency asdefined by the plan this will bepaid at the Network Level.

Chiropractic Evaluation

and Management

$20 co-pay then 100%deductible waived

Not covered

Chiropractic/Spinal

ManipulationLabs/x-rays/supplies24 visits Calendar Year maximum


Custom Molded Foot

Orthotics


Diabetic Supplies(see the Prescription Drug section fordiabetic medications covered under thePrescription Drug Program)


Diagnostic MRI/MRA scans

Office/Outpatient

$50 co-pay to 3 co-pays perCalendar Year but not forreadings

Not covered

Diagnostic CAT scans

Office/Outpatient

$50 co-pay to 3 co-pays perCalendar Year but not forreadings

Not covered

Diagnostic Lab/X-ray all

other tests and readings


Durable Medical Equipment 90% deductible waived Not covered

Home Health Care50 visits Calendar Year maximum


Hospice Care 100% deductible waived Not covered

Injections office 100% deductible waived Not covered

Injections

Inpatient/Outpatient/Home


OrthoticsIncludes orthotics for back/neck, etc.See above for Custom Molded FootOrthotics.


Other Covered Services 100% deductible waived Not covered

Physician Emergency Room

Visits


Physician Inpatient Visits 100% deductible waived Not covered


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NETWORK PROVIDERS


PROVIDERS


Physician Office Visits PCP* - $5 co-pay then 100%deductible waived

Specialist with referral - $5 co-pay then 100% deductiblewaived

Specialist without referral - $20co-pay then 100% deductiblewaived$5 co-pay for first 3 months(1/1/11 to 3/31/11)

Not covered

Primary Care Providers (PCP) include:

Pediatricians; OB/GYN (please see Coordinated Care section for definition of OB/GYN as specialist); General Practitioner; Family Practice Provider; DOS (Dr. of Osteopath) Internist; and Registered Nurse Practitioners.

All other providers will be considered specialists.

Co-pay Options:

One co-pay per day, per visit (will apply one co-pay even if more than one provider billsfrom that visit)

Co-pay applies to office visit fee only (E&M) and all other charges same day pay as noted in the

Schedule of Benefits regardless of whether an office visit fee is billed.Physician Outpatient Visits 100% deductible waived Not covered

Private duty nursingInpatient only


Prosthetics 90% deductible waived Not covered

Supplies Non Durable Office 90% deductible waived Not covered

Supplies Non Durable Other 90% deductible waived Not covered

Surgery below includes professional fees for anesthesia and assistant surgeon

Surgery Inpatient 100% deductible waived Not covered

Surgery Office 100% deductible waived Not covered

Surgery Outpatient 100% deductible waived Not covered

Urgent Care Clinic

Evaluation and Managementfees(Free-standing facility)

$20 co-pay then 100%

deductible waived

Not covered

Urgent Care Clinic Lab/x-ray/supplies/surgery(Free-standing facility)



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NETWORK PROVIDERS


PROVIDERS


COVERED SERVICES HOSPITAL FEES - See separate categories for Infertility,

Preventive, Psychiatric Care, Organ Transplants, Rehabilitation, Jaw Joint/TMJ, and

PregnancyInpatient Room and BoardLimited to the semiprivate room rate


Intensive Care UnitLimited to the Hospitals ICU Charge


Inpatient MiscellaneousCharges


Outpatient Emergency Room $75 co-pay then 100%deductible waived

Co-pay is waived if admitted

Not covered

Outpatient MRI/MRA scans $50 co-pay to 3 co-pays perCalendar Year but not for

readings then 100% deductiblewaived

Not covered

Outpatient CAT Scans $50 co-pay to 3 co-pays perCalendar Year but not forreadings then 100% deductiblewaived

Not covered

Outpatient Diagnostic all

other tests


Outpatient Surgery 100% deductible waived Not covered

Outpatient Other Services 100% deductible waived Not covered

Skilled Nursing Facility45 days Calendar Year maximum


Urgent Care Room(Hospital billed)


Not covered

Outpatient Clinic Fee(Hospital billed)


COVERED SERVICES FOR BOTH PROFESSIONAL AND HOSPITAL FEES FOR THEFOLLOWING DIAGNOSES:Infertility Benefits(see the Prescription Drug section forinfertility medications covered underthe Prescription Drug Program)


Includes: care, supplies and services for the diagnosis of infertility. Treatment of infertility isnot covered.

Jaw Joint/TMJ$1,250 Calendar Year maximum

Paid as any other illness tomaximum

Not covered

Wig after Chemotherapy 100% deductible waived 100% deductible waived

Organ Transplants 100% deductible waived Not covered

Organ Transplants Meal,

Lodging & Travel Expenses$10,000 maximum per transplant


Pregnancy Paid same as any other illness Not covered


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NETWORK PROVIDERS


PROVIDERS


Preventive Care age 18 and

olderRoutine Well Care

The following are consideredroutine:

MammogramsPap smearProstate screeningRoutine surgeries(colonoscopy,sigmoidoscopy, proctoscopy,etc)ImmunizationsRoutine hearing examRoutine eyes exam 1 examper Calendar YearX-raysAll other lab tests


Preventive Care up to age

18Routine Well Child CareThe following are consideredroutine:

Routine physical examX-raysRoutine hearing examRoutine eye exam 1 exam

per Calendar YearImmunizationsAll other lab tests


Psychiatric Care - Mental Disorders & Substance Abuse

Inpatient Facility andResidential Treatment Thisincludes any services whiledone during an inpatient orresidential stay


Emergency Room $75 co-pay then 100%deductible waived

Co-pay is waived if admitted

Not covered

Urgent Care Room(Hospital Billed)


Not covered

Outpatient Facility and otherTransitional Treatment - Thisincludes any services billed asoutpatient or in a partial stayfacility



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NETWORK PROVIDERS


PROVIDERS


Diagnostic X-ray & Labs allother tests and readings


Urgent Care Clinic Evaluationand Management fees(Free standing facility)


Not covered

Urgent Care Clinic Lab/x-ray/supplies/surgery(Free standing facility)


REHABILITATION THERAPY FOR BOTH PROFESSIONAL AND HOSPITAL FEES

(Inpatient hospital fees are included in inpatient miscellaneous hospital fees above)

Cardiac Rehabilitation(Office/Outpatient)


Chemo/Radiation Therapy(Office/Outpatient)


Hemodialysis Treatment(Office/Outpatient) 100% deductible waived Not covered

Pulmonary Rehabilitation 100% deductible waived Not covered

Occupational Therapy(Office/Outpatient)


Physical Therapy(Office/Outpatient)


Speech Therapy(Office/Outpatient)



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PPO Benefit Plan Option

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NETWORK PROVIDERS


PROVIDERS


Ambulance Service 90% after deductible Paid at Network Level

Chiropractic/Spinal

Manipulation24 visits per Calendar Year maximum

90% after deductible 70% after deductible

Custom Molded Foot

Orthotics




Diagnostic Lab/X-ray

Emergency Room


Diagnostic Lab by

Independent Lab





Diagnostic Lab/X-ray Office 90% after deductible 70% after deductible

Diagnostic X-ray Office

Radiologist Fees


Durable Medical Equipment 90% after deductible 70% after deductible

Home Health Care50 visits Calendar Year maximum


Hospice Care 100% deductible waived 100% deductible waived

Injections office 90% after deductible 70% after deductible

Injections



Orthotics

Includes orthotics for back/neck etc.See above for Custom Molded FootOrthotics.


Other Covered Services 90% after deductible 70% after deductible


Visits


Physician Inpatient Visits 90% after deductible 70% after deductible

Physician Office Visits Primary Care Provider* andSpecialists with referrals

95% deductible waived

This applies to the Evaluationand Management fee only. Allother services rendered in the

office will pay at 90% afterdeductible.

70% after deductible


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NETWORK PROVIDERS


PROVIDERS





Physician Office Visits Specialists without referrals


Physician Outpatient Visits 90% after deductible 70% after deductible



Prosthetics 90% after deductible 70% after deductibleSupplies Non Durable Office 90% after deductible 70% after deductible

Supplies Non Durable Other 90% after deductible 70% after deductible


Surgery Inpatient 90% after deductible 70% after deductible

Surgery Office 90% after deductible 70% after deductible

Surgery Outpatient 90% after deductible 70% after deductible

Urgent Care Clinic(Free-standing facility)










Outpatient Emergency Room 90% after deductible 70% after deductible

Outpatient Diagnostic 90% after deductible 70% after deductible

Outpatient Surgery 90% after deductible 70% after deductible

Outpatient Other Services 90% after deductible 70% after deductible

Skilled Nursing Facility45 days Calendar Year maximum







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NETWORK PROVIDERS


PROVIDERS


COVERED SERVICES FOR BOTH PROFESSIONAL AND HOSPITAL FEES FOR THE

FOLLOWING DIAGNOSES:Infertility Benefits(see the Prescription Drug section forinfertility medications covered underthe Prescription Drug Program)

Paid as any other illness Paid as any other illness

Includes: care, supplies and services for the diagnosis of infertility. Treatment of infertility isnot covered.




Wig after Chemotherapy 90% after deductible Paid at Network Level

Organ Transplants 90% after deductible 70% after deductible

Organ Transplants Meal,

Lodging & Travel Expenses

$10,000 maximum per transplant

100% deductible waived 100% deductible waived

Pregnancy Paid as any other illness Paid as any other illness


olderRoutine Well CareThe following are consideredroutine:

MammogramsPap smearProstate screeningRoutine surgeries(colonoscopy)

ImmunizationsRoutine vision exam 1 perCalendar YearRoutine hearing examX-raysAll other lab tests


Preventive Care up to age 18Routine Well Child CareThe following are consideredroutine:

Routine physical examX-rays

Routine hearing examRoutine vision exam 1 perCalendar YearImmunizationsAll other lab tests



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NETWORK PROVIDERS


PROVIDERS



Inpatient Facility andResidential Treatment Thisincludes any services whiledone during an inpatient orresidential stay


Emergency Room 90% after deductible 70% after deductible



Outpatient Facility and otherTransitional Treatment - Thisincludes any services billed asoutpatient or in a partial stay

facility


Office Evaluation andManagement fees - PrimaryCare Provider* and Specialistswith referrals


This applies to the Evaluationand Management fee only. Allother services rendered in theoffice will pay at 90% afterdeductible.





Office Evaluation andManagement fees - Specialistswithout referrals


Office Counseling fees Primary Care Provider andSpecialists with referrals


This applies to the Evaluationand Management fee only. All

other services rendered in theoffice will pay at 90% afterdeductible.


Office Counseling fees Specialists without referrals


Diagnostic Lab & X-ray-office



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HSA Benefit Plan Option

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NETWORK PROVIDERS


PROVIDERS


Allergy Testing



Ambulance Service 100% after deductible Paid at Network Level

Chiropractic/Spinal

Manipulation24 visits per Calendar Year maximum


Custom Molded Foot

Orthotics





Emergency Room


Diagnostic Lab by

Independent Lab





Diagnostic Lab/X-ray Office 100% after deductible 80% after deductible

Diagnostic X-ray Office

Radiologist Fees


Durable Medical Equipment 100% after deductible 80% after deductible

Home Health Care50 visits Calendar Year maximum.


Hospice Care 100% after deductible 80% after deductible

Injections office 100% after deductible 80% after deductible

Injections



OrthoticsIncludes orthotics for back/neck, etc.See above for Custom Molded FootOrthotics.


Other Covered Services 100% after deductible 80% after deductible


Visits


Physician Inpatient Visits 100% after deductible 80% after deductible

Physician Office VisitsPrimary Care Provider* andSpecialists with referrals



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NETWORK PROVIDERS


PROVIDERS





Physician Office VisitsSpecialists without referral

Deductible then $20 co-paybalance paid at 100%


Physician Outpatient Visits 100% after deductible 80% after deductible



Prosthetics 100% after deductible 80% after deductibleSupplies Non Durable Office 100% after deductible 80% after deductible

Supplies Non Durable Other 100% after deductible 80% after deductible


Surgery Inpatient 100% after deductible 80% after deductible

Surgery Office 100% after deductible 80% after deductible

Surgery Outpatient 100% after deductible 80% after deductible

Urgent Care Clinic(Free-standing facility)










Outpatient Emergency Room 100% after deductible 80% after deductible

Outpatient Diagnostic 100% after deductible 80% after deductible

Outpatient Surgery 100% after deductible 80% after deductible

Outpatient Other Services 100% after deductible 80% after deductible

Skilled Nursing Facility

45 days Calendar Year maximum






COVERED SERVICES FOR BOTH PROFESSIONAL AND HOSPITAL FEES FOR THE

FOLLOWING DIAGNOSES:


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NETWORK PROVIDERS


PROVIDERS


Infertility Benefits(see the Prescription Drug section forinfertility medications covered under

the Prescription Drug Program)

Paid as any other illness Paid as any other illness

Includes: care, supplies and services for the diagnosis of infertility. Treatment of infertility is notcovered.


Paid same as any other illnessto maximum

Paid same as any other illness tomaximum

Wig after Chemotherapy 100% after deductible Paid at Network level

Organ Transplants 100% after deductible 80% after deductible

Organ Transplants Meals,

Lodging & Travel Expenses$10,000 maximum per transplant


Pregnancy Paid same as any other illness Paid same as any other illness


olderRoutine Well CareThe following are consideredroutine:

MammogramsPap smearProstate screeningRoutine surgeries(colonoscopy)Immunizations

Routine hearing examRoutine vision exam 1 perCalendar YearX-raysAll other lab tests


Preventive Care up to age 18Routine Well Child CareThe following are consideredroutine:

Routine physical examX-raysRoutine hearing exam

Routine vision exam 1 perCalendar YearImmunizationsAll other lab tests



Inpatient Facility and ResidentialTreatment This includes anyservices while done during aninpatient or residential stay



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NETWORK PROVIDERS


PROVIDERS


Speech Therapy(Office/Outpatient)



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PRESCRIPTION DRUG BENEFITFOR EPO PLAN

Pharmacy OptionLimited to a 34-day supply

Generic drugs

Co-payment .................................................................................................... $10

Brand Name drugs

Payable Percentage ......................................................................................... 30%

The maximum out-of-pocket is $1,500 for single coverage and $3,000 for family coverage. .Aftermaximum prescription out-of-pocket has been met; Tier 2 drugs will graduate to a $10 co-payment.

Mail Order Prescription Drug OptionAvailable for maintenance drugs. Maintenance drugs are those taken for long periods of time, such as drugssometimes prescribed for heart disease, high blood pressure, asthma, etc.

Limited to a 90-day supply

Generic drugs

Co-payment .................................................................................................... $20

Brand Name drugs


The maximum out-of-pocket is $1,500 for single coverage and $3,000 for family coverage. Aftermaximum prescription out-of-pocket has been met; Tier 2 drugs will graduate to a $20 co-payment.


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PRESCRIPTION DRUG BENEFIT

FOR PPO PLAN

Pharmacy OptionLimited to a 34-day supply

Generic drugs

Co-payment .................................................................................................... $10

Brand Name drugs



Mail Order Prescription Drug OptionAvailable for maintenance drugs. Maintenance drugs are those taken for long periods of time, such as drugssometimes prescribed for heart disease, high blood pressure, asthma, etc.

Limited to a 90-day supply

Generic drugs

Co-payment .................................................................................................... $20

Brand Name drugs




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ELIGIBILITY

EMPLOYEE ELIGIBILITY: Employees who belong to an Eligible Class of employees are eligiblefor coverage under this Plan following the waiting period.

ELIGIBLE CLASS:

Full-time, Active Employees or Part Time Active Employees who work for The Employer at least30 hours per week for an average of forty-eight (48) weeks per year and is on the regular payrollof the Employer for that work. Eligible employees also include the owner(s) of Trek BicycleCorporation and partner(s) in Trek Bicycle Corporation.

Trek Bicycle may enter into a written contract with an independent contractor that includesmedical coverage under the Plan during the term of the written contract, subject to theindependent contractor paying the full cost of coverage.

WAITING PERIOD: An Employee is eligible on the first day that he/she is a Full-Time, ActiveEmployee of the Employer or a Part Time Active Employee who normally works at least 30 hours per

week for an average of 48 weeks per year and is on the regular payroll of the Employer for that work.

To be eligible on the date of hire, an Employee must enroll within 31 days of the date of hire. Coveragethen becomes effective on the date of hire for Eligible Employees of Trek Bicycle Corporation andindependent contractors.

A group health plan may not base rules for eligibility for coverage upon an individual being actively atwork, if a health factor is present. If a plan participant is absent from work due to a health factor, forpurposes of plan eligibility, the individual is to be considered actively at work.

EMPLOYEE EFFECTIVE DATE

Employee coverage under the Plan shall become effective on the date of the Employees eligibilityprovided he/she has made written application for such coverage on or before such date. The Employeemust apply for coverage within 31 days of eligibility for coverage to be effective on the date of eligibility.Please see the Enrollment section for all requirements of Timely, Special and Late enrollees.

DEPENDENT ELIGIBILITY

The following persons are eligible for dependent coverage under this plan:

1. LAWFUL SPOUSE An Employees lawful spouse in the state of residence, living in the samecountry, if not legally separated or divorced. The Plan Administrator may require documentationproving a legal marital relationship.

The term Spouse shall also mean the person who is currently registered with the Employer asthe domestic partner of the Employee, this includes domestic partners of the opposite and samesex. An Individual is a domestic partner of an Employee if that individual and the Employeemeet each of the following requirements:

a. The Employee and individual are 18 years of age or older and are mentally competent toenter into a legally binding contract.

b. The Employee and the individual are not married to anyone.


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c. The Employee and the individual are not related by blood to a degree of clones that wouldprohibit legal marriage between individuals of the opposite sex in the state in with theyreside.

d. The Employee and the individual share the same principal residence(s), the commonnecessities of life, the responsibility of each others welfare, are financially interdependentwith each other and have a long-term committed personal relationship in which each

partner is the others sole domestic partner. Each of the foregoing characteristics of thedomestic partner relationship must have been in existence for a period of at least twelve(12) consecutive months and be continuing during the period that the applicable benefits isprovided. The Employee and the individual must have the intention that their relationshipwill be indefinite.

e. The Employee and the individual have common or joint ownership of a residence (home,condominium, or mobile home), motor vehicle, checking account, credit account, mutualfund, joint obligation under a lease for their residence or similar type ownership.

In the event the domestic partnership is terminated, either partner is required to inform TrekBicycle Corporation of the termination of the partnership.

If a divorce is pending, a Spouse cannot be dropped from coverage until the divorce is finalized.A finalized divorce decree must be submitted in order to drop Spouses coverage from this Plan.

Spousal Transfer Provision

If both spouses are Employees and each has taken single coverage under this Plan, this Planpermits the spouse to take coverage as a Dependent at any time. In addition, if both spouses areEmployees and eligible for coverage under this Plan, and the spouse previously waived coverageas an Employee in favor of coverage as a Dependent, this Plan permits the spouse to takecoverage as an Employee under the Plan and to enroll any other eligible Dependents asDependents of the spouse when:

1. The Employees decide to transfer coverage under the Plan from one spouse to theother spouse; or2. A spouse decides to take coverage as an Employee for any reason; or3. Coverage under the Plan is terminated for any reason.

2. CHILDREN TO AGE 26 -- An Employees child up to age 26 is eligible for coverage throughthis plan regardless of marital status or employment status. If the child has other employer-basedcoverage available to them either through their own employer or through the employer of theirSpouse or Domestic Partner, then the child is not eligible for coverage through this plan. Whenthe child reaches limiting age, coverage will end on the childs birthday.

3. DEVELOPMENTLY DISABLED OR PHYSICALLY HANDICAPPED CHILDREN AnEmployee's unmarried Dependent child who is incapable of self-sustaining employment byreason of Developmental Disability or physical handicap, primarily dependent upon theparticipant for support and maintenance and covered under this Plan when the child reaches thelimiting age. Proof of physical or mental handicap must be submitted to the Plan Administratorwithin thirty-one (31) days of the covered Dependent reaching the limiting age. Thereafter, proofmay be required annually.

4. CHILDREN ENTITLED TO COVERAGE as the result of one of the following:a) Qualified Medical Child Support Order (QMCSO);


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b) A National Medical Support Order;c) Divorce Decree; andd) Court Order.

The term "child" or "children" as referenced in the above sections includes:a) An Employee's natural child;b) An Employee's adopted child (from the date of placement);c) An Employee's stepchild;d) An Employees foster child;e) Any other child for whom the Employee has legal guardianship or for a child for whom the Employee

had noted legal guardianship on the childs 18th birthday (proof is required).

An adopted child (from the date of placement) refers to a child whom the Employee has adopted orintends to adopt, whether or not the adoption has become final, who has not attained the age of eighteenon the date of such placement for adoption. The term placement means the assumption and retention bysuch Employee of a legal obligation for total or partial support of the child in anticipation of adoption ofthe child. The child must be available for adoption and the legal process must have commenced.

At any time, the Plan may require proof that a Spouse or a child qualifies or continues to qualify as aDependent as defined by the Plan.

If a person covered under this Plan changes status from Employee to Dependent or Dependent toEmployee, and the person is covered continuously under this Plan before, during and after the change instatus, credit will be given for deductibles and all amounts applied to maximums.

If both mother and father or domestic partner are Employees, their children will be covered asDependents of the mother or father or domestic partner, but not of both.

Excluded Dependents include: other individuals living in the covered Employees home, but who are noteligible as defined; the legally separated or divorced former spouse of the Employee; any person who is

on active duty in any military service of any country; any former domestic partner of the Employee; orany person who is eligible for coverage under this Plan as an Employee.

DEPENDENT EFFECTIVE DATE

A Dependent will be considered eligible for coverage on the date the Employee becomes eligible forDependent Coverage, subject to all limitations and requirements of this Plan. Each Employee who makessuch written request for Dependent Coverage on a form approved by the Employer shall, become coveredfor Dependent Coverage as follows:

1. If the Employee makes such written request on or before the date he or she becomes eligible forDependent Coverage, or within the time frame listed in "Employee Eligibility" to enroll, the

Employee shall become covered, with respect to those persons who are then his or herDependents, on the date he or she becomes covered for participant coverage.

2. If the Dependent is a Newborn child or newly adopted child, then the Dependent is eligible forcoverage from the date of the event (i.e., birth or date of placement). The newly-acquiredDependent is automatically enrolled if family coverage is in place. Benefits will not be paid untilthe Dependent is enrolled. The Pre-Existing Conditions Limitation does not apply to NewbornDependent children or adopted children if enrollment is made within thirty-one (31) days of thedate of birth or date of placement.


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3. If a Dependent is acquired other than at the time of his birth due to a court order, decree, ormarriage, coverage for this new Dependent will be effective on the date of such court order,decree, or marriage if Dependent Coverage is in effect under the Plan at that time and properenrollment is completed within thirty-one (31) days of the event. If the Employee does not haveDependent Coverage in effect under the Plan at the time of the court order, decree, or marriage

and requests such coverage and properly enrolls this new Dependent within the thirty-one (31)day period immediately following the date of the court order, decree, or marriage, thenDependent Coverage will be retroactive to the date of the court order, decree, or marriage.

TIMELY ENROLLMENT

The enrollment will be timely if the enrollment form is completed no later than 31-days after the personbecomes eligible for the coverage, either initially or under a Special Enrollment Period. The 12-monthPre-Existing Condition limitation provision may apply.

If two Employees (husband and wife or domestic partners) are covered under this Plan and the Employeewho is covering the Dependent children terminates coverage, the Dependent coverage may be continued

by the other covered Employee as long as coverage has been continuous.

LATE ENROLLMENT

Enrollment for coverage is required within thirty-one (31) days of the date an individual would otherwisebe eligible. If enrollment is not completed within that time, or if a covered Employee's and/or Dependent'scoverage terminates because of failure to make a contribution when due, such person will be considered alate enrollee. Some late enrollments may be made under the following Special Enrollment provision;however, if the Special Enrollment provisions do not apply, the Late Enrollee will be effective the first ofthe month following application. The eighteen (18) month Pre-Existing Condition limitation of this Planwill apply to all Late Enrollees who do not qualify to enroll under the Special Enrollment provision.

SPECIAL ENROLLMENT PERIODS

The enrollment date for anyone who enrolls under a Special Enrollment Period is the first date ofcoverage. Thus, the time between the date a Special Enrollee first becomes eligible for enrollment underthe Plan and the first day of coverage is not treated as a Waiting Period.

Individuals losing other coverage (proof is required). An Employee or Dependent, who iseligible, but not enrolled in this Plan, may enroll if each of the following conditions is met:

1. The Employee or Dependent was covered under a group health plan or had healthinsurance coverage or coverage through a state Medicaid or Childrens HealthInsurance Program (CHIP) program, at the time coverage under this Plan waspreviously offered to the individual.

2. If required by the Plan Administrator, the Employee stated in writing at the time thatcoverage was offered that the other health coverage was the reason for decliningenrollment.

3. The coverage of the Employee or Dependent who had lost the coverage was underCOBRA and the COBRA coverage was exhausted, or was not under COBRA and:


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The coverage of the Dependent enrolled in the Special Enrollment Period will be effective:

1. in the case of marriage, the first day of the month coinciding with or next followingthe date of application, or in the case of domestic partnership, on the date ofregistration of the domestic partner relationship;

2. in the case of a Dependent's birth, as of the date of birth; or3. in the case of a Dependent's adoption or placement for adoption, the date of the

adoption or placement for adoption;

4. in the case of a loss of coverage through Medicaid or CHIP, the date of the loss ofsaid coverage.

Pre-existing Condition Exclusion and Special Enrollees

Special enrollees and their Dependents will not be treated as late enrollees. The Plan will apply a Pre-

Existing Condition exclusion period of twelve (12) months to a special enrollee. The Plan will not apply aPre-Existing Condition exclusion to any enrollee under the age of 19, situations of Pregnancy or to aNewborn or adopted child who is enrolled under the special enrollment provisions.

Special Enrollment Period for Dependents up to Age 26 and Participants previously Terminateddue to reaching a Lifetime Limit under this Plan

For a Dependent who had coverage ended, or was denied coverage (or was not eligible for coverage)under this Plan because, under the terms of the plan or coverage, the availability of dependent coverage ofchildren ended before the attainment of age 26, the Plan is providing a one-time Special EnrollmentOpportunity. The opportunity to enroll begins on the first day of the first plan year beginning on or afterSeptember 23rd, 2010, and continues for 30 days, regardless of whether the Plan offers an open enrollment

period and regardless of when any open enrollment period might otherwise occur.

For an individual whose Child had coverage ended, or was denied coverage (or was not eligible forcoverage) under this Plan because the individual had reached a lifetime maximum dollar level for claimsunder the Plan, the Plan is providing a one-time Special Enrollment Opportunity. The opportunity toenroll begins on the first day of the first plan year beginning on or after September 23rd, 2010, andcontinues for 30 days, regardless of whether the Plan offers an open enrollment period and regardless ofwhen any open enrollment period might otherwise occur.

Additionally, if the individual is not enrolled in the Plan, or if an enrolled individual is eligible for but notenrolled in any benefit package under the Plan, then the Plan is providing the individual with anopportunity to enroll that continues for at least 30 days starting on the first day of the first plan year

beginning on or after September 23, 2010.

OPEN ENROLLMENT

Every November 1, the annual open enrollment period, covered Employees and their covered Dependentswill be able to change some of their benefit decisions based on which benefits and coverages are right forthem.


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Benefit choices made during the open enrollment period will become effective January 1 and remain ineffect until the next January 1 unless there is a Special Enrollment event of a change in family statusduring the year (birth, death, marriage, divorce, adoption) or loss of coverage due to loss of a Spousesemployment. To the extent previously satisfied, Pre-Existing Conditions Limits will be consideredsatisfied when changing from one benefit option under the Plan to another benefit option under the Plan.

A Plan Participant who fails to make election during open enrollment will automatically retain his or herpresent coverage.

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


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PRE-EXISTING CONDITIONS

A Pre-Existing Condition is a disease, Injury, or Sickness of a Covered Person for which the CoveredPerson has been under the care of a licensed Physician or has received medical care, services, or supplieswithin the six (6) month period prior to the Covered Persons enrollment date.

Timely Enrollees:For a Covered Person who enrolls in this Plan within thirty-one (31) days after the date of his eligibilityfor coverage (Timely Enrollees) claims in relation to or resulting from Pre-Existing Conditions will beexcluded from coverage under the Plan until the Covered Person has been employed by the Employer fora period of twelve (12) consecutive months. At that point, the Pre-Existing Conditions Limitation will nolonger apply, and all eligible charges incurred thereafter will be considered under the Plan.

Special Enrollees:For a Covered Person who enrolls in the Plan under the Special Enrollment (Special Enrollees), claims inrelation to or resulting from Pre-Existing Conditions will be excluded from coverage under the Plan untilthe Covered Person has been enrolled under the Plan for a period of twelve (12) consecutive months. Atthat point, the Pre-Existing Conditions Limitation will no longer apply, and all eligible charges incurred

thereafter will be considered under the Plan.

Late Enrollees:For a Covered Person who enrolls in this Plan more than thirty-one (31) days after the date of hiseligibility for coverage (Late Enrollees), claims in relation to or resulting from Pre-Existing Conditionsare excluded from coverage under the Plan until the Covered Person has been enrolled under the Plan fora period of eighteen (18) consecutive months. At that point, the Pre-Existing Conditions Limitation willno longer apply, and all eligible charges incurred thereafter will be considered under the Plan.

Exceptions to the Pre-Existing Condition Limitation:

1. The Plan's Pre-Existing Condition exclusion does not apply to any person who is under the age of19, in cases of Pregnancy, or to a Newborn, an adopted child under age nineteen (19), or a childplaced for adoption under age nineteen (19), if the child becomes covered within thirty-one (31)days of birth, adoption or placement for adoption.

2. The Pre-Existing Condition Limitation will be waived wholly or in part in the event a CoveredPerson was insured previously by Creditable Coverage, and providing there was no break in suchcoverage longer than sixty-three (63) days immediately prior to: 1) for new hires, the date ofemployment; or 2) for Special and Late Enrollees, the date of enrollment in this Plan. Any timeperiods used to satisfy the Covered Persons Pre-Existing Condition Limitation under the priorplan will be credited towards the satisfaction of this Plan's Pre-Existing Conditions Limitation, tothe extent that such time was satisfied under the prior plan.

For the purposes of this Plan, "Creditable Coverage" means, with respect to a Covered Person, coverageof an individual provided under any of the following:

a. Part A or Part B of Title XVIII of the Social Security Act (Medicare);b. A group health plan;c. An individual health insurance policy that provides benefits similar to or exceeding

benefits provided under a basic health benefit plan;


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d. Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely ofbenefits under section 1928 (the program for distribution of pediatric vaccines);

e. Chapter 55 of Title 10, United States Code (military-sponsored health care);f. A State health benefits risk pool;g. A health plan offered under chapter 89 of Title 5, United States Code (FEHBP);h. A public health plan (as defined in the regulations);i. A medical care program of the Indian Health Service or of a tribal organization;j. A health benefit plan under section 5(e) of the Peace Corps Act (22 D.S.C. 2504(e));k. A public health plan provided by a foreign country; orl. A Childrens Health Insurance Program of any State.


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CARE COORDINATION PROCESS

I. Introduction

The Plan incorporates a Care Coordination process based on a program called CoordinatedHealth/Care. This program includes a staff of Care Coordinators who receive a notification regarding

most healthcare services sought by Covered Members, and coordinate activities and information flowbetween the providers.

Care Coordination is intended to help Covered Members obtain quality healthcare and services in themost appropriate setting, help reduce unnecessary medical costs, and for early identification of complexmedical conditions. The Care Coordinators are available to Covered Members and their providers forinformation, assistance, and guidance, and can be reached toll-free by calling:

Care Coordinators: 1-866-498-0137

II. Process of Care Requirements

A. OverviewDesignated Coordinating PhysicianUpon enrollment, all Covered Members are asked to designate a coordinating Primary Care Physician(PCP) for each member of their family. While such designation is not mandatory, it is stronglyrecommended. To ensure the highest level of benefits, all Covered Members should designate anin-network primary care physician to be their coordinating Physician.

It is recommended that the Covered Member begin every healthcare event with a call or visit to theirdesignated PCP, who will issue a referral for specialty care as required. However, referral notices canbe submitted by any PCP, including non-network providers. Please note: an office visit to a non-network PCP would be covered at the non-network benefit level. The referral will be authorized for acertain time period, number of visits, or number of units, as requested by the PCP. During the

authorized period, further referrals are not required for additional visits or treatments associated withthe initial referral.

The Schedule of Benefits included in the Summary Plan Document specifies the benefit reductionthat occurs for specialty services that are received without an authorized specialty referral in place.

The care coordination process generally begins with the coordinating Physician, who is a PrimaryCare Physician who maintains a relationship with the Covered Member and provides generalhealthcare guidance, evaluation, and management. The following types of physicians can be selectedby Covered Members as their coordinating PCP:

Family Physician General Practice Internal Medicine Pediatrician (for children) DOS (Dr. of Osteopath) Registered Nurse Practitioner An OB/GYN may serve as a primary care physician


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have been provided with materials and education regarding this referral process.) While the referralprocess is initiated by the PCP, the Covered Member is ultimately responsible for ensuring that thereferral authorization is in place before the specialty visit. Whenever possible, notice of this referral issent to the Covered Member; however, Covered Members can verify that the referral is in place by callingthe Care Coordinators at 1-866-498-0137 or visiting the website on your ID card. Referrals submissionswill not be accepted after the specialty service has been received. Please refer to Emergency Admissions

and Procedures for additional information regarding those circumstances.

2. Pre-Certification of Certain ProceduresTo be covered at the highest level of benefit and to ensure complete care coordination, the Plan requiresthat certain care, services and procedures be pre-certified before they are provided. Pre-certificationrequestsare submitted to the Care Coordinators by a specialty Physician, designated PCP, other PCP, orother healthcare provider. Provider offices have been provided with materials and education regardingthis referral process and your Plan identification card includes instructions. Depending on the request, theCare Coordinators may contact the requesting provider to obtain additional clinical information to supportthe need for the pre-certification request and to ensure that the care, service and/or procedure meet Plancriteria. If a pre-certification request does not meet Plan criteria, the Care Coordinators will contact theCovered Member and healthcare provider and assist in redirecting care if appropriate. The following

services require pre-certification:

Inpatient and Skilled Nursing Facility Admissions Outpatient Surgeries MRI/MRA and PET scans Oncology Care and Services (chemotherapy and radiation therapy) Home Health Care Hospice Care DME all rentals and any purchase over $500 Organ, Tissue and Bone Marrow Transplants Dialysis

Occupational, Physical and Speech Therapy

PENALTIES FOR NOT OBTAINING PRE-CERTIFICATION:

A non-notification penalty is the amount you must pay if notification of the service is not provided priorto receiving a service. A penalty of $250 will be reduced from the facility charge if a Covered Memberreceives services but did not obtain the required certification for:

Inpatient Admissions Skilled Nursing Facility Admissions

3. Utilization ReviewThe Care Coordinators will revieweach pre-certification request to evaluate whether the care, requestedprocedures, and requested care setting all meet utilization criteria established by the Plan. The Plan hasadopted the utilization criteria in use by the Coordinated Health/Care program. If a pre-certificationrequest does not meet these criteria, the request will be reviewed by one of the local medical directors forCoordinated Health/Care, who will review all available information and if needed consult with therequesting provider. If required, the medical director will also consult with other professionals andmedical experts with knowledge in the appropriate field. He or she will then provide, through the Care


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Coordinators, a recommendation to the Plan Administrator whether the request should be approved,denied, or allowed as an exception. In this manner, the Plan ensures that pre-certification requests arereviewed according to community standards of medical care, based on community healthcare resourcesand practices.

4.Concurrent Review

The Coordinated Health/Care program will regularly monitor a hospital stay, other institutional admission,or ongoing course of care for any Covered Member, and examine the possible use of alternate facilities orforms of care. The Care Coordinators will communicate regularly with attending Physicians, the UtilizationManagement staff of such facilities, and the Covered Member and/or family, to monitor the patientsprogress and anticipate and initiate planning for future needs (discharge planning). Such concurrent review,and authorization for Plan coverage of hospital days, is conducted in accordance with the utilizationcriteria adopted by the Plan and Coordinated Health/Care.

5. Case ManagementCase Management is ongoing, proactive coordination of a Covered Members care in cases where themedical condition is, or is expected to become catastrophic, chronic, or when the cost of treatment isexpected to be significant. Examples of conditions that could prompt case management intervention

include but are not limited to, cancer, chronic obstructive pulmonary disease, multiple trauma, spinal cordinjury, stroke, head injury, AIDS, multiple sclerosis, severe burns, severe psychiatric disorders, high riskpregnancy, and premature birth.

Case Management is a collaborative process designed to meet a covered Members health care needs,maximize their health potential, while effectively managing the costs of care needed to achieve thisobjective. The case manager will consult with the Covered Member, the attending physician, and othermembers of the Covered Members treatment team to assist in facilitating/implementing proactive plansof care which provides the most appropriate health care and services in a timely, efficient and cost-effective manner.

If the case manager, covered Member, and the Plan Administrator all agree on alternative care that can

reasonably be expected to achieve the desired results without sacrificing the quality of care provided, thePlan Administrator may alter or waive the normal provisions of this Plan to cover such alternative care, atthe benefit level determined by the Plan Administrator.

In developing an alternative plan of treatment, the case manager will consider:

The covered Member's current medical status The current treatment plan The potential impact of the alternative plan of treatment The effectiveness of such care and The short-term and long-term implicationsthis treatment plan could have

The Plan Administrator retains the right to review the covered Member's medical status while the alternativeplan of treatment is in process, and to discontinue the alternative plan of treatment with respect to medicalservices and supplies which are not covered charges under the Plan if:

The attending physician does not provide medical records or information necessary todetermine the effectiveness of the alternative plan of treatment

The goal of the alternative care of treatment has been met


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The alternative plan of care is not achieving the desired results or is no longer beneficial to thecovered Member; or

The Maximum benefit under the Plan has been reached.General Provisions for Care Coordination

A. Authorized RepresentativeThe Covered Member is ultimately responsible for ensuring that all referrals and pre-certifications areapproved and in place prior to the time of service to receive the highest level of benefits. However, inmost cases, the actual referral and pre-certification process will be executed by the Covered MembersPhysician(s) or other providers. By subscribing to this Plan, the Covered Member authorizes the Plan andits designated service providers (including Coordinated Health/Care, the third party administrator, andothers) to accept healthcare providers making referral and pre-certification submissions, or who otherwisehave knowledge of the Covered Members medical condition, as their authorized representative in mattersof Care Coordination. Communications with and notifications to such healthcare providers shall beconsidered notification to the Covered Member.

B. Time of Notice

The referral and pre-certification notifications must be made to Coordinated Health/Care within thefollowing timeframe:

At least three business days, before a scheduled (elective) Inpatient Hospital admission By the next business day after, an emergency Hospital admission or procedure Upon being identified as a potential organ or tissue transplant recipient At least three business days before receiving any other services requiring pre-authorization

C. Emergency admissions and proceduresAny Hospital admission or Outpatient procedure that has not been previously scheduled and cannot bedelayed without harming the patients health is considered an emergency for purposes of the utilizationreview notification.

D. Maternity AdmissionsA notice regarding admissions for childbirth should be submitted to the Care Coordinators in advance,preferably 30 days prior to expected delivery. The Plan and the Care Coordination process complies withall state and federal regulations regarding utilization review for maternity admissions. The Plan will notrestrict benefits for any Hospital stay in connection with childbirth for the mother or newborn child to lessthan 48 hours following a normal vaginal delivery, or less than 96 hours following a cesarean section, orrequire prior certification or authorization for prescribing a length of stay not in excess of these periods.If the mother's or newborn's attending provider, after consulting with the mother, discharges the mother orher newborn earlier than the applicable 48 or 96 hours, the Plan will only consider benefits for the actuallength of the stay. The Plan will not set benefit levels or out-of-pocket costs so that any later portion ofthe 48 or 96 hour stay is treated in a manner less favorable to the mother or newborn than any earlier

portion of the stay.

E. Care Coordination is not a guarantee of payment of benefitsThe Care Coordination process does not provide a guarantee of payment of benefits. Approvals ofreferral and pre-certification notices for specialty visits, procedures, hospitalizations and other services,indicate that the medical condition, services, and care settings meet the utilization criteria established bythe Plan. The Care Coordination approvals do not indicate that the service is a covered benefit, that theCovered Member is eligible for such benefits, or that other benefit conditions such as co-pay, deductible,


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co-insurance, or maximums have been satisfied. Final determinations regarding coverage and eligibilityfor benefits are made by the Plan.

F. Result of not following the coordinated process of careFailure to comply with the Care Coordination process of care may result in reduction or loss inbenefits. The Schedule of Benefits included in this Plan Document specifies such reduction in benefits.

The Penalties for not obtaining pre-certification section specifies applicable penalties. Charges you mustpay due to any penalty for failure to follow the care coordination process do not count toward satisfyingany deductible, co-insurance or out-of-pocket limits of the Plan.

G. Appeal of Care Coordination determinationsCovered Members have certain appeal rights regarding adverse determinations in the Care Coordinationprocess, including reduction of benefits and penalties. The appeal process is detailed in the Claims andAppeal Procedures section within this document.


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MEDICAL EXPENSE BENEFITS

Upon receipt of a claim, the Plan will pay the benefit percentage listed in the Schedule of Benefits forEligible Expenses incurred in each benefit period. The amount payable, in no event, shall exceed theMaximum Plan Year Benefit stated in the Schedule of Benefits.

The Deductible

The Deductible is the amount of covered medical expenses which must be paid by the Covered Personbefore Medical Expense Benefits are payable. The amount of the Deductible is shown in the Schedule ofBenefits. Each Family member is subject to the Deductible up to the Family maximum as shown in theSchedule of Benefits. The Exclusive Provider Organization (EPO) Plan is not subject to the deductible.

Family Deductible Feature

If the Family Deductible limit, as shown in the Schedule of Benefits, is incurred by covered Familymembers during the Calendar Year, no further Deductibles will be required on any members for the restof the year.

Usual and Customary Charges

Subject to the Plan Administrators exercise of discretion, the Plan shall pay no more than the Usual andCustomary Charge for covered services and/or supplies, after a deduction of all amounts payable bycoinsurance or deductibles. All charges must be billed in accordance with generally accepted industrystandards.

The Usual and Customary Charge shall be the average payment actually made for reasonably comparableservices and/or supplies to all providers of the same services and/or supplies by all types of plans in thesame market area during the preceding Calendar Year, adjusted by the national Consumer Price Indexmedical care rate of inflation. The Plan Administrator shall determine the average plan payment made and

applicable market area using reasonably available information.

The Plan Administrator may increase or decrease the amount payable based upon discretionaryconsideration of factors including the nature and severity of the condition being treated, the quality of thegoods and/or services provided, and competitive factors affecting the reasonable availability of alternativesources for the services and/or supplies in the relevant geographic market during the relevant time period.In making such determinations the Plan Administrator may exercise discretion to the full extent permittedby law.

Out-of-Pocket Limit

Covered charges are payable at the percentage shown each Calendar Year until the Out-of-Pocket limit

shown in the Schedule of Benefits is reached. Then, covered charges incurred by a Covered Person willbe payable at 100% (except for the charges excluded) for the rest of the Calendar Year.

When a family reaches the family Out-of-Pocket limit, covered charges for that family will be payable at100% (except for the charges excluded) for the rest of the Calendar Year.

The Exclusive Provider Organization (EPO) Plan is not subject to the out-of-pocket limit.


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Maximum Plan Year Benefit Amount

The Maximum Plan Year Benefit Amount is shown in the Schedule of Benefits. It is the total amount ofbenefits that will be paid under all Plans for all covered charges incurred by a Covered Person. If theEmployer offers more than one (1) Employee Health Care Plan a Covered Person who has reached thePlan Year Maximum under one Plan will not be eligible for benefits under any other Employer Health

Care Plan.

Allocation and Apportionment of Benefits

The Employer reserves the right to allocate the Deductible amount to any eligible charges and toapportion the benefits to the Covered Person and any assignees. Such allocation and apportionment shallbe conclusive and shall be binding upon the Covered Person and all assignees.

Alternative Treatment

In addition to the Covered Medical Expenses specified, the Claims Administrator (on behalf of and inconjunction with the Plan Administrator) may determine and pre-authorize other services to be covered

hereunder which normally are excluded services or have limited coverage under this Plan. The attendingPhysician or Case Manager must submit an Alternative Care plan to the Claims Administrator whichindicates the diagnosis and Medical Necessity of the proposed medical services to be provided to theCovered Person.

Based on this information, the Claims Administrator and/or its Medical Consultant(s) will determine andapprove the period of time for which such medical service(s) will be covered under this Plan. Further, theClaims Administrator will make such a determination based on each circumstance and stipulate that itsapproval does not obligate this Plan to provide coverage for the same or similar services for otherCovered Persons nor be construed as a waiver of its rights to administer this Plan in accordance with itsestablished provisions.

Medical Eligible Expenses

Medical Eligible Expenses are the following expenses that are incurred while coverage is in force for theCovered Person. If, however, any of the listed expenses are excluded from coverage because of a reasondescribed in the General Limitations section, those expenses will not be considered Medical EligibleExpenses.

The Plan will make payment for Medical Eligible Expenses subject to the benefit percentage andmaximum amounts shown in the Schedule of Benefits.

Hospital Expenses

Hospital expenses are the charges made by a Hospital in its own behalf. Such charges include:

1. Room charges made by a Hospital having only private rooms will be paid at 80% of the averageprivate room rate.

2. Necessary Hospital services other than room and board as furnished by the Hospital, includingbut not limited to, general nursing services.

3. Special care units, including burn care units, cardiac care units, delivery rooms, Birthing Centers,Intensive Care Units, isolation rooms, Rehabilitation facilities, Ambulatory Surgical Centers,operating rooms and recovery rooms.


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Plan reserves the right to require a second opinion with a provider mutually agreeable to theCovered Persons family and this Plan.

Intensive-Level services. The Covered Person is eligible for 4 cumulative years of intensivelevel services. Any previous intensive-level services received by the Covered Person will becounted against this requirement under this Policy, regardless of payor.

Intensive level services must be consistent with the following:o Evidence based.o Provided by a qualified provider as defined by state law.o Based on a treatment plan developed by a qualified provider or professional as

defined by state law that includes the average of 20 or more hours per week over asix-month period of time with specific cognitive, social, communicative, self-care orbehavioral goals that are clearly defined, directly observed and continually measured.Treatment plans shall require the Covered Person be present and engaged inintervention.

o Provided in an environment most conducive to achieving the goals of the CoveredPersons treatment plan.

o Includes training and consultation, participation in team meetings and activeinvolvement of the Covered Persons family and treatment team for implementationof the therapeutic goals developed by the team.

o Commences after the Covered Person is 2 years of age and before the CoveredPerson is 9 years of age.

o Services must be assessed and documented throughout the course of treatment.o The Covered Person must be directly observed by the qualified provider at least once

every two months.

Nonintensive-Level Services The Covered Person is eligible for nonintensive-level services, includingdirect or consultative services, that are evidence-based and are provided by a qualified provider orqualified paraprofessional if one of the following conditions apply:

After the completion of intensive-level services and designed to sustain and maximize gains madeduring intensive-level treatment.

To a Covered Person who has not and will not receive intensive-level services but for whom non-intensive level services will improve the Covered Persons condition.

Nonintensive-Level Services must be consistent with the following:o The services are based upon a treatment plan and includes specific therapy goals

that are clearly defined, directly ob

Trek 2011 Healthcare Plan Summary

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Transcript of Trek 2011 Healthcare Plan Summary