Employee Compensation & Benefits HandbookEmployee Compensation & Benefits Handbook MP 01 2019 Page 5 of 60 Same-sex spouses can be covered under the plan as long as valid marriage

Employee Compensation

& Benefits Handbook

MP 01 2019 Page 1 of 60

H E A L T H C A R E P L A N

INTRODUCTION ......................................................................................................................................................... 4 GENERAL INFORMATION ........................................................................................................................................ 4 ELIGIBLE EMPLOYEES AND DEPENDENTS ......................................................................................................... 4

Eligible Employees .................................................................................................................................................... 4 Eligible Dependents ................................................................................................................................................... 4 Domestic Partners ...................................................................................................................................................... 5 Qualified Medical Child Support Orders ................................................................................................................... 5 Enrollment and Date of Coverage ............................................................................................................................. 6 Qualified Status Changes ........................................................................................................................................... 6 Annual Enrollment .................................................................................................................................................... 7 Special Enrollment Rights under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIP) .. 7 Employee Medical Contributions .............................................................................................................................. 7 Company Retiree Medical Contributions and Coverage after December 31, 2014 ................................................... 7 Spousal Premium ....................................................................................................................................................... 8

HEALTH CARE PLAN OPTIONS .............................................................................................................................. 8 PPO 500-90/10 (Local 1289) ..................................................................................................................................... 9 Summary of PPO 500-90/10 Benefits ....................................................................................................................... 9 PPO 500-70/30 ........................................................................................................................................................ 11 Summary of PPO 500-70/30 Benefits ..................................................................................................................... 12 Consumer High Deductible Health Plan (HDHP) ................................................................................................... 14 Summary of the Consumer HDHP Benefits ............................................................................................................ 15 Enhanced High Deductible Health Plan (HDHP) .................................................................................................... 17 Summary of the Enhanced HDHP Benefits ............................................................................................................. 18 Base PPO ................................................................................................................................................................. 20 Summary of the Base PPO Benefits ........................................................................................................................ 21 Medicare Preferred (LPPO) Base Plan .................................................................................................................... 23 Your Member ID Card............................................................................................................................................. 25 Member Services ..................................................................................................................................................... 25 Mental Health and Chemical Dependency Care ...................................................................................................... 25 Life Resources (Employee Assistance Program) ..................................................................................................... 25

PROGRAMS OFFERED BY THE HEALTH CARE PLAN ..................................................................................... 26 Quick Care Options ................................................................................................................................................. 26 AIM Imaging Cost & Quality Program ................................................................................................................... 26 24/7 NurseLine ........................................................................................................................................................ 26 Future Moms............................................................................................................................................................ 27 LiveHealth Online ................................................................................................................................................... 27 Health Care Management ........................................................................................................................................ 27 Medical Specialty Drugs Administered by a Medical Provider ............................................................................... 28 Voluntary Site of Care Redirection Program ........................................................................................................... 28 Types of Requests .................................................................................................................................................... 28

SERVICES COVERED BY THE HEALTH CARE PLAN ....................................................................................... 29 Hospital Benefits ..................................................................................................................................................... 29 Room and Board ...................................................................................................................................................... 29 Other Hospital Services and Supplies ...................................................................................................................... 29 Doctor’s Hospital Visits .......................................................................................................................................... 30 Newborn Care .......................................................................................................................................................... 30 Emergency Admissions ........................................................................................................................................... 30 Hospital Expenses Not Covered .............................................................................................................................. 30 Covered Surgical Benefits ....................................................................................................................................... 30 Outpatient Surgery ................................................................................................................................................... 31 OTHER BENEFITS ................................................................................................................................................ 31


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Preadmission Testing ............................................................................................................................................... 31 Emergency Care ...................................................................................................................................................... 31 Obstetrical Care ....................................................................................................................................................... 32 Out-Of-Area Care .................................................................................................................................................... 32 Doctor’s Office and Home Visits ............................................................................................................................ 32 Wellness Benefits .................................................................................................................................................... 32 Routine Gynecological Exams and Mammograms .................................................................................................. 32 Outpatient Short-Term Rehabilitation including Physical Therapy, Radiotherapy and Speech Therapy ................ 33 Outpatient Diagnostic X-rays and Lab Exams ......................................................................................................... 33 Treatment of Mouth Conditions .............................................................................................................................. 33 Miscellaneous Services and Supplies ...................................................................................................................... 33 Mental Health and Chemical Dependency Benefits ................................................................................................ 34

EXTENDED CARE SERVICES ................................................................................................................................ 34 Home Health Care ................................................................................................................................................... 34 Convalescent Care ................................................................................................................................................... 34 Hospice Care............................................................................................................................................................ 35 Vision Care .............................................................................................................................................................. 35 What the Health Care Plan Does Not Cover ............................................................................................................ 35

Definition of Terms ..................................................................................................................................................... 36 Inter-Plan Arrangements .............................................................................................................................................. 37

Out-of-Area Services ............................................................................................................................................... 37 Inter-Plan Arrangements Eligibility – Claim Types ................................................................................................. 38 A. BlueCard® Program ........................................................................................................................................... 38 B. Negotiated (non–BlueCard Program) Arrangements .......................................................................................... 38 C. Special Cases: Value-Based Programs ................................................................................................................ 38 D. Inter-Plan Programs: Federal/State Taxes/Surcharges/Fees ................................................................................ 39 E. Nonparticipating Providers Outside the Claims Administrator’s Service Area ................................................... 39 F. Blue Cross Blue Shield Global Core ® Program ................................................................................................ 39 How Claims are Paid with Blue Cross Blue Shield Global Core ............................................................................ 39 Assignment .............................................................................................................................................................. 40 Maximum Allowed Amount .................................................................................................................................... 40 Member Cost Share ................................................................................................................................................. 42 Authorized Services ................................................................................................................................................. 43 Services Performed During Same Session ............................................................................................................... 43

HOW TO SUBMIT A CLAIM .................................................................................................................................... 43 If You Are Hospitalized........................................................................................................................................... 43 Doctor’s Services ..................................................................................................................................................... 44 Coordination of Benefits.......................................................................................................................................... 44

COORDINATION WITH MEDICARE ..................................................................................................................... 45 When the FirstEnergy Health Care Plan is Primary ................................................................................................ 45 Third Party Liability and Subrogation ..................................................................................................................... 46 Assignment and Responsibility for Payment ........................................................................................................... 46 Notification of Payment ........................................................................................................................................... 46

BENEFIT CLAIMS AND APPEALS PROCEDURES .............................................................................................. 47 Claims Process ......................................................................................................................................................... 47 Appeals Process ....................................................................................................................................................... 48 Legal Claims ............................................................................................................................................................ 49

CLAIMS AND APPEALS OTHER THAN FOR BENEFITS .................................................................................... 49 Initial Claim Decision for Claims Relating to Eligibility and Participation ............................................................ 50 Appeals of Denied Claims Relating to Eligibility and Participation ....................................................................... 50 Legal Claims ............................................................................................................................................................ 51

BENEFITS UPON TERMINATION .......................................................................................................................... 51 Termination of Coverage ......................................................................................................................................... 51 Your Rights to Continued Health Care Coverage .................................................................................................... 51


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How to Continue Coverage ..................................................................................................................................... 52 The Cost of Continued Coverage............................................................................................................................. 52 When Continued Coverage Ends ............................................................................................................................. 52 Conversion to an Individual Health Insurance Policy ............................................................................................. 53

HIPAA PRIVACY NOTICE ....................................................................................................................................... 53 Seeking assistance from Human Resources ............................................................................................................. 53

LEGISLATIVE CHANGES ........................................................................................................................................ 54 Mental Health Parity and Addiction Equity Act ...................................................................................................... 54

OTHER FACTS AND INFORMATION .................................................................................................................... 54 Certificate of Credible Coverage ............................................................................................................................. 54 Benefit Rights .......................................................................................................................................................... 54 Source of Benefits ................................................................................................................................................... 54 VEBA ...................................................................................................................................................................... 55 Participant’s Rights .................................................................................................................................................. 55 Plan is Not an Employment Contract ...................................................................................................................... 56 Right to Amend Plan ............................................................................................................................................... 56 Administration ......................................................................................................................................................... 56 Plan Sponsor ............................................................................................................................................................ 56 Type of Plan............................................................................................................................................................. 57 Plan Number ............................................................................................................................................................ 57 Agent for Service of Legal Process ......................................................................................................................... 57 Fiscal Year ............................................................................................................................................................... 57

PARTICIPATING EMPLOYERS AND IDENTIFICATION NUMBERS ................................................................ 57 PARTICIPATING UNIONS ....................................................................................................................................... 58


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INTRODUCTION Health care benefits are an important part of the FirstEnergy Corp. Flexible Benefits Program. The FirstEnergy Health Care Plan and the FirstEnergy Prescription Drug Plan are separate plans. This document contains the summary description for the FirstEnergy Health Care Plan (the Plan). There is a separate summary plan description for the FirstEnergy Prescription Drug Plan. For most employees the Plan consists of plan options for Preferred Provider Organizations (PPOs), two High Deductible Health Plans (HDHP), and a retiree Medicare Preferred (LPPO) Base Plan. Based on your status as either an active employee or retiree and your union affiliation, the number of options available to you may differ. The information you receive each year as part of the annual enrollment process will indicate the plan options that are available to you. The following description of the Plan has been prepared to help you gain a better understanding of its terms and conditions effective January 1, 2019. Each employee’s benefits and rights under the Plan are governed at all times by the official contracts with the various medical plan administrators, and are in no way altered or modified by the contents of this summary. If you have questions after reviewing this material, contact the Human Resources Service Center or your local Human Resources Office for assistance.

GENERAL INFORMATION For the purposes of this summary, the term “Company” means the operating companies, subsidiaries and affiliates of FirstEnergy Corp. to which the Plan has been extended (see section entitled “Participating Employers”).

ELIGIBLE EMPLOYEES AND DEPENDENTS

Eligible Employees All non-bargaining full-time regular, and part-time regular employees, and certain temporary employees and retired employees of the Company are eligible to participate in this Plan. In addition, the surviving spouse of an employee or eligible retiree may be eligible to participate. Employees represented by a labor union as indicated in the section titled “Participating Unions” may participate to the extent provided by their respective collective bargaining agreement with the Company.

Eligible Dependents You may also enroll your eligible dependents, which include your legal spouse, and your child (ren) through the end of the month of their 26th birthday, including adopted children, foster children, stepchildren and older children who are incapable of self-support due to a physical or mental disability and children for which you’ve been granted legal custody by a court of competent jurisdiction. Proof of disability and proof that the dependent is financially dependent upon his or her parents must be provided to the administrator within 31 calendar days of the date the child would otherwise become ineligible for Plan participation. Proof of incapacitation must be provided to Anthem before the child becomes ineligible at or beyond age 26. Medical updates may be required periodically. If your child is incapable of self-support, contact Anthem to complete necessary forms.


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Same-sex spouses can be covered under the plan as long as valid marriage certificate is provided to the Human Resources Service Center. If both you and your spouse work for the Company, you may both choose single medical coverage or you may elect coverage for yourself and your spouse. If you choose to cover your spouse, then your spouse must elect no coverage. If both you and your spouse elect separate coverage, then only one parent may elect to cover eligible dependent children. It is fraudulent to enroll any dependent or other person not eligible for coverage or fail to notify the Company of a change in eligibility for a covered dependent. Dismissal from employment, criminal or civil penalties can result from such acts. The Plan retains the right to verify the eligibility of your dependents and failure to provide sufficient documentation determined by the Plan Administrator to verify eligibility will result in loss of coverage for the plan year.

Domestic Partners Employees are eligible to cover their domestic partner on their health care coverage. Domestic partner criteria require that you and your partner must be at least age 18 and have lived together 12 months in an exclusive relationship mutually responsible for each other’s welfare demonstrated by three or more of the following:

o Common ownership of real property and/or a motor vehicle; o Driver’s license with common address; o Joint bank and/or credit accounts; o Designation as primary beneficiary for life insurance or retirement benefits, or under a partner’s

will; o Assignment of durable power of attorney or health care power of attorney.

In addition, you must not be related to each other to a degree of closeness that would prohibit legal marriage in your residence state, married to anyone else or in the relationship for the sole purpose of obtaining benefits coverage. You will be responsible for payment of applicable taxes as a result of FirstEnergy providing health care benefits to your domestic partner. To add a domestic partner to your health care, you will be required to complete a Domestic Partner Declaration form and provide appropriate documentation.

Qualified Medical Child Support Orders The Consolidated Omnibus Budget Reconciliation Act of 1993 (COBRA) requires group health plans, such as this Plan, to recognize “qualified medical child support orders” by providing benefits for participants’ children in accordance with these orders. Upon receipt of an order, the Human Resources Department will follow these procedures: 1. Promptly notify the participant and each Alternate Recipient (participant’s child) that the order has been

received and inform them of the procedures for determining if the order is a Qualified Medical Child Support Order (QMCSO).

A QMCSO is one that:

♦ Does not require the Plan to provide any type or form of benefit that is not already offered; ♦ Either creates or recognizes the right of an Alternate Recipient to receive benefits for which a

participant is entitled under the group health plan;


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♦ Includes the name and address of the participant and the Alternate Recipient; ♦ Includes a description of the type of coverage to be provided by the group health plan or the manner

in which such coverage is to be determined; and ♦ Specifies the period for which coverage must be provided and each plan to which it applies.

2. Review the Order to determine if it qualifies as a QMCSO. If necessary, the Order will be forwarded

to the Company’s Legal Department for review. The participant and any Alternate Recipient will be notified of the determination.

3. If the Order is determined to be a QMCSO, inform the Alternate Recipient that a representative (custodial parent or guardian) may be designated to receive any required notices. Also, the Order would specify to whom the Plan would make any payments or reimbursements.

4. Provide the Alternate Recipient or representative a copy of this summary plan description. Also, a

supply of claim forms will be provided.

If you are required to provide health coverage as the result of a Qualified Medical Child Support Order issued on or after the date your coverage becomes effective, any Plan provisions which require evidence of good health, limits due to a pre-existing condition, or coverage delays due to a confinement will not apply to the initial health coverage for this child. If you are the non-custodial parent, proof of claim for such child may be given by the custodial parent. Benefits for such claims will be paid to the custodial parent.

Enrollment and Date of Coverage You are eligible to participate in the Plan on the first day of the month following your date of hire. During the first month of your employment, you will receive a Flexible Benefits enrollment form to complete to designate your medical plan election. Coverage begins on your eligibility date if you have enrolled. If you do not return an enrollment form, you will automatically default to waive medical coverage.

Qualified Status Changes Notification: You must notify the Human Resources Service Center (‘HRSC’) and complete the necessary form within 31 calendar days of any change in family status – such as marriage, birth of a child, divorce, or a child who is no longer an eligible dependent. However, there are two special rules. If adding a new dependent does not require a change of your premium, you can add the dependent by notifying the HRSC even if you fail to notify the HRSC within 31 calendar days. If adding a new dependent does require a change of your premium and you miss the 31-day deadline, you can still add your new dependent by notifying the HRSC. However, you must pay the increased cost for the new level of coverage on an after-tax basis beginning on the effective date of coverage. Effective Date of New Dependent Coverage: Contingent upon the requisite notification, changes in coverage are effective on the first day of the month following the date the HRSC receives the required notification, except that newborn children are covered from the date of birth and coverage for an adopted child under age 18 will begin on the date the child is placed with you for adoption. These are the only situations in which retroactive coverage will be provided.


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Annual Enrollment Open enrollment is announced and conducted in the fall each year as part of the Flexible Benefits enrollment period. It is your annual opportunity to change your election for coverage. Changes in coverage made during the annual enrollment period are effective the following January 1. Information about your medical and prescription drug plan options is available from the Human Resources Service Center or your local Human Resources Office. Special Enrollment Even if an eligible employee did not enroll in the plan during open enrollment, a person who becomes a dependent of the employee after the beginning of the plan year as a result of marriage, birth or adoption or placement for adoption may be entitled to a dependent special enrollment provided the employee notifies the HRSC within 31 days of the date of the marriage, birth, or adoption.

Special Enrollment Rights under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIP) The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIP) requires employer-sponsored group health plans to permit an employee who is eligible, but not enrolled, for coverage under the plan (or a dependent of such an employee if the dependent is eligible, but not enrolled for coverage) to enroll if either of the following conditions is met:

• The employee or dependent covered under Medicaid or CHIP has coverage terminated as a result of loss of eligibility, or

• The employee or dependent becomes eligible for a premium assistance subsidy under Medicaid or CHIP.

If either of the above conditions is met, you must notify the Human Resources Service Center and complete the necessary forms within 60 days of the date coverage terminates under Medicaid or CHIP, or within 60 days of the determination of eligibility for a premium assistance subsidy.

Employee Medical Contributions The cost of medical coverage and employee contributions are determined by the Company and communicated during the annual Flexible Benefits enrollment period. The Company contributes 45% (50% for Local 1289) of the cost of Plan coverage for part-time employees who are regularly scheduled to work 20 or more hours per week. Part-time employees who are scheduled to work less than 20 hours per week may still participate in the Plan but must pay the full cost of elected coverage. Employee contributions will be deducted from your paycheck on a before-tax basis. The level of benefits and employee contributions required for medical coverage are subject to change at the discretion of the Company and in accordance with the current agreements reached between the Company and the participating unions.

Company Retiree Medical Contributions and Coverage after December 31, 2014 The Company announced in March 2011 that subsidized monthly payments toward retiree health coverage, which includes prescription coverage, would end as of December 31, 2014. This change affects eligible current employees as well as eligible current retirees. Eligible retirees who are younger than age 65 will have access to the government planned health care exchanges (as a result of the federal health care legislation) or a Private Exchange through Via Benefits (formerly OneExchange); or may choose to maintain coverage under the FirstEnergy Access Plan, which includes Rx Base prescription drug coverage


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as part of the Base PPO medical coverage, by paying the full premium. Health and prescription drug coverage can’t be unbundled. This premium is based on retiree claims experience and is not rated with the active employee plan. Retirement health care benefits are not vested and the Company retains the discretion to amend or terminate the FirstEnergy Access Plan. The termination of the subsidized monthly payments toward retiree health coverage may not apply to all retirees, such as those with individualized contracts or those who are covered under the terms of a collective bargaining agreement which specifically provides for a continuation of a subsidy. For those employees continuing eligibility for a subsidy, the Company’s contribution toward the cost of medical coverage will reflect your age and years of service at retirement, as shown below. The contribution required for a surviving spouse of an active employee is based on the employee’s age and service at the time of the employee’s death.

Your Age + Service Company's Contribution 85+ Cost of elected coverage less employee contribution

75-84 75% of cost of elected coverage less employee contribution 65-74 50% of cost of elected coverage less employee contribution

Pursuant to the terms of their collective bargaining agreement, IBEW Local1289 retirees receive a different subsidy and participate in a different plan design than other retirees who remain eligible for a subsidy. For persons who retire as the result of a disability and are eligible to continue coverage at retirement, age and service will be determined based on the effective date of their disability retirement. As long as the employee had 10 years of service, a minimum of 65 will be used to determine the monthly contribution. Retirees enrolled in the FirstEnergy Access Plan will be billed by Wageworks for the full premium. Premiums will not be deducted from your monthly retirement check.

Spousal Premium Applies to full-time bargaining and non-bargaining regular employees, except employees represented by Local 29, Local 102, Local 272, Local 777, and Local 1289. If your spouse is working full-time (at least 32 hours per week) and is eligible for employer-subsidized medical and prescription drug coverage, employees who elect coverage for their spouses will be charged an additional spousal premium of $200 per month. A change in qualified status throughout the year that results in your spouse not having employer-subsidized coverage permits you to add your spouse to coverage without a charge for the premium.

HEALTH CARE PLAN OPTIONS The FirstEnergy Health Care Plan offers you substantial protection for a wide range of medical expenses and the flexibility to choose the right medical option for you and your family. The Plan offers most employees the choice of one of three options – Consumer HDHP, Enhanced HDHP or Base PPO. Local 1289 members are also offered the PPO 500-90/10 Plan. Many retirees are offered the Base PPO and the Consumer HDHP. Medicare-eligible retirees in the GPU Pre-1996 Local 180 and 459 retiree group are eligible for the PPO 500-70/30. In addition to the PPO plans, most Medicare eligible retirees are offered the Medicare Preferred (LPPO) Base plan. An explanation of each of the options follows.


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PPO 500-90/10 (Local 1289) The PPO 500-90/10 is administered by Anthem Blue Cross and Blue Shield. Like the other PPO options, PPO 500-90/10 requires that all care be received from network providers in order to receive a higher level of benefits. Coverage at a reduced level is available from the PPO 500- 90/10 if care is received out of network. In-network care is reimbursed at 90% after a $500 annual deductible per covered individual with a maximum family deductible of $1,000. After the annual out-of-pocket maximum of $3,500 per person or $6,500 per family for in-network care is reached, the plan will reimburse 100% of eligible expenses. In-network wellness care is covered at 100% with no annual deductible. This benefit coverage is aimed at monitoring your medical status before problems arise. A chart of preventive services is located on Anthem’s website at www.anthem.com. A link to the document is available on the Health and Wellness tab of www.myfirstrewards.com. Click on the Preventive Health Guidelines link under the Medical icon. Care provided outside of the network is reimbursed at 60% of the maximum allowed amount after a $1,500 annual deductible per covered individual, with a maximum annual family deductible of $3,000. After the annual out-of-pocket maximum of $6,500 per person or $12,500 per family for out-of-network care is reached, the plan will reimburse 100% of eligible expenses. Benefits for all out-of-network care are subject to Maximum Allowed Amount set by the administrator. Prescription drug deductibles, co-pays and coinsurance do not apply to PPO 500-90/10 deductibles and out-of-pocket maximums. In-network expenses cannot be used to satisfy the out-of-network deductible or out-of-pocket maximum. Likewise, out-of-network expenses cannot be used to satisfy the in-network deductible or applied to the out-of-pocket maximum for in-network care. If you seek out-of-network care, you will be responsible for filing claim forms and for obtaining advance approvals (pre-certification) from the administrator for any inpatient hospital care and outpatient procedures, services, and tests. In addition, when you receive covered services from an out of network provider, you may be responsible for paying any difference between the maximum allowed amount and the provider’s actual charges. You should call a member services representative at the toll-free number shown on your ID card to initiate the pre-certification process. The administrator will gather information from your doctor about your condition and the recommended treatment to determine the level of coverage for the proposed care. PPO 500-90/10 does not contain a preexisting condition limitation.

Summary of PPO 500-90/10 Benefits The following chart provides a summary of the benefits available through PPO 500-90/10. All covered expenses must be for medically necessary services. All out-of-network care is subject to Maximum Allowed Amount.

PPO 500 90/10 SUMMARY OF BENEFITS

Plan Features In-Network Benefits Out-of-Network Benefits¹

http://www.anthem.com/

http://www.myfirstrewards.com/


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Deductible Per calendar year

$500 per person $1,000 family maximum

$1,500 per person $3,000 family maximum

Health Reimbursement Account Not applicable

Out-of-Pocket Maximum Per calendar year, including deductible

$3,500 individual $6,500 family maximum

Excludes prescription drug deductibles and co-pays

$6,500 individual $12,500 family maximum Excludes prescription drug

deductibles and co-pays

Coordination of Benefits Maintenance of Benefits Maintenance of Benefits Inpatient Care

Hospital Room & Board 90% after deductible 60% after deductible Other Hospital Services and Supplies 90% after deductible 60% after deductible

Physician Hospital Services 90% after deductible 60% after deductible Surgeon and Assistant Surgeon 90% after deductible 60% after deductible

Emergency Care² 90% after deductible 60% after deductible³

Convalescent Care 60 day maximum, up to 50% of cost of semi-private hospital room

90% after deductible 60% after deductible

Outpatient Services Outpatient Surgery 90% after deductible 60% after deductible Physician Office Visits Unless part of wellness care 90% after deductible 60% after deductible

Outpatient Physical, Radiological and Speech Therapy


Durable Medical Equipment 90% after deductible 60% after deductible Other Covered Services

Home Health Care 100 visits per calendar year up to 50% of cost of semi-private hospital room


Private Duty Nursing When medically necessary, 15 days per calendar year



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Hospice - Inpatient 30 day maximum up to 50% of cost of semi-private hospital room


Hospice - Outpatient 90% after deductible 60% after deductible Wellness Benefits⁴

Well baby care Primary care physician (PCP) can include doctor practicing family medicine or pediatrician

100% No deductible or coinsurance Not covered

Physical Assessment Per schedule and by PCP only; PCP can include doctor practicing internal or family medicine, or pediatrician


Routine GYN Exam Performed by PCP only; PCP can include doctor practicing family medicine or gynecology


Mammogram When recommended by PCP or gynecologist; one per year


¹ All out-of-network care subject to Maximum Allowed Amount. ² You will be responsible for additional $250 co-pay by the carrier if your visit is determined to be non-emergency. ³ Emergency care, as defined on page 39, received at an out-of-network facility will be paid at the higher network level benefit. ⁴ A chart of preventive services is located on Anthem’s website at www.anthem.com. A link to the document is available on the Health and Wellness tab of www.myfirstrewards.com. Click on the Preventive Health Guidelines link under the Medical icon.

PPO 500-70/30 This plan is offered to Medicare-eligible retirees in the former GPU Pre-1996 Local 180 and 459 group. The PPO 500-70/30 is administered by Anthem Blue Cross and Blue Shield.




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Like the other PPO options, PPO 500-70/30 requires that all care be received from network providers in order to receive a higher level of benefits. Coverage at a reduced level is available from PPO 500-70/30 if care is received out of network. In-network care is reimbursed at 70% after a $500 annual deductible per covered individual with a maximum family deductible of $1,000. After the annual out-of-pocket maximum of $3,500 per person or $6,500 per family for in-network care is reached, the plan will reimburse 100% of eligible expenses. In-network wellness care is covered at 100% with no annual deductible. This benefit coverage is aimed at monitoring your medical status before problems arise. A chart of preventive services is located on Anthem’s website at www.anthem.com. A link to the document is available on the Health and Wellness tab of www.myfirstrewards.com. Click on the Preventive Health Guidelines link under the Medical icon. Care provided outside of the network is reimbursed at 60% of the maximum allowable amount after a $1,500 annual deductible per covered individual, with a maximum annual family deductible of $3,000. After the annual out-of-pocket maximum of $6,500 per person or $12,500 per family for out-of-network care is reached, the plan will reimburse 100% of eligible expenses. Benefits for all out-of-network care are subject to Maximum Allowed Amount set by the administrator. Prescription drug deductibles, co-pays and coinsurance do not apply to PPO 500-70/30 deductibles and out-of-pocket maximums. In-network expenses cannot be used to satisfy the out-of-network deductible or out-of-pocket maximum. Likewise, out-of-network expenses cannot be used to satisfy the in-network deductible or applied to the out-of-pocket maximum for in-network care. If you seek out-of-network care, you will be responsible for filing claim forms and for obtaining advance approvals (pre-certification) from the administrator for any inpatient hospital care and outpatient procedures, services, and tests. In addition, when you receive covered services from an out of network provider, you may be responsible for paying any difference between the maximum allowed amount and the provider’s actual charges. You should call a member services representative at the toll-free number shown on your ID card to initiate the pre-certification process. The administrator will gather information from your doctor about your condition and the recommended treatment to determine the level of coverage for the proposed care. PPO 500-70/30 does not contain a preexisting condition limitation.

Summary of PPO 500-70/30 Benefits The following chart provides a summary of the benefits available through PPO 500-70/30. All covered expenses must be for medically necessary services. All out-of-network care is subject to Maximum Allowed Amount.

PPO 500 70/30 SUMMARY OF BENEFITS

Plan Features In-Network Benefits Out-of-Network Benefits¹ Deductible Per calendar year







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¹ All out-of-network care subject to Maximum Allowed Amount ² You will be responsible for additional $250 co-pay by the carrier if your visit is determined to be non-emergency. ³ Emergency care, as defined on page 39, received at an out-of-network facility will be paid at the higher network level benefit. ⁴ A chart of preventive services is located on Anthem’s website at www.anthem.com. A link to the document is available on the Health and Wellness tab of www.myfirstrewards.com. Click on the Preventive Health Guidelines link under the Medical icon.

Consumer High Deductible Health Plan (HDHP) The Consumer HDHP is combination of a high deductible health plan and a tax-advantaged savings account that can be used to pay for medical and prescription drug expenses. Medical benefits are administered by Anthem Blue Cross and Blue Shield. Like the other PPO options, the Consumer HDHP requires that all care be received from network providers in order to receive a higher level of benefits. Coverage at a reduced level is available from the Consumer HDHP if care is received out of network. A health savings account is a tax advantaged savings account that can be used to pay current medical and prescription drug expenses as well as to save for future expenses - including retirement. Contributions, earnings and distributions are exempt from federal income and Social Security taxes when used to pay for qualified medical expenses. You own and manage your HSA. Money left in your account at the end of the year rolls over into the next year.




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In-network care is reimbursed at 80% after applicable co-payments and/or a $2,700 annual deductible per covered individual with a maximum family deductible of $5,200. The family deductible and out-of-pocket maximum amount can be satisfied by any combination of family members but an individual would never need to satisfy more than their own individual deductible and out-of-pocket maximum amount. This is an embedded deductible. After the annual out-of-pocket maximum of $5,500 per person or $11,000 per family for in-network care is reached, the plan will reimburse 100% of eligible expenses. In-network wellness care is covered at 100%. A chart of preventive services is located on Anthem’s website at www.anthem.com. A link to the document is available on the Health and Wellness tab of www.myfirstrewards.com. Click on the Preventive Health Guidelines link under the Medical icon. Care provided outside of the network is reimbursed at 60% of the maximum allowed amount after a $5,000 annual deductible per covered individual and a $10,000 annual family deductible. After the annual out-of-pocket maximum of $10,000 per person or $20,000 per family for out-of-network care is reached, the plan will reimburse 100% of eligible expenses. Benefits for all out-of-network care are subject to a Maximum Allowed Amount set by the administrator. Prescription drug costs apply to the Consumer HDHP deductibles and out-of-pocket maximums. See the Prescription Drug Summary Plan Description for details. In-network expenses cannot be used to satisfy the out-of-network deductible or out-of-pocket maximum. Likewise, out-of-network expenses cannot be used to satisfy the in-network deductible or applied to the out-of-pocket maximum for in-network care. If you seek out-of-network care, you will be responsible for filing claim forms and for obtaining advance approvals (pre-certification) from the administrator for any inpatient hospital care and outpatient procedures, services, and tests. In addition, when you receive covered services from an out of network provider, you may be responsible for paying any difference between the maximum allowed amount and the provider’s actual charges. You should call a member services representative at the toll-free number shown on your ID card to initiate the pre-certification process. The administrator will gather information from your doctor about your condition and the recommended treatment to determine the level of coverage for the proposed care. Participants in the Consumer HDHP plan are encouraged to review IRS Publication 969 regarding HSA requirements. The Consumer HDHP does not contain a preexisting condition limitation.

Summary of the Consumer HDHP Benefits The following chart provides a summary of the benefits available through the Consumer HDHP. All covered expenses must be for medically necessary services. All out-of-network care is subject to a Maximum Allowed Amount.

CONSUMER HDHP SUMMARY OF BENEFITS







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$5,500 individual $11,000 family maximum Includes prescription drug




















Hospice - Outpatient 80% after deductible 60% after deductible


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Wellness Benefits⁴









¹ All out-of-network care subject to Maximum Allowed Amount ² You will be responsible for additional $250 co-pay by the carrier if your visit is determined to be non-emergency. ³ Emergency care, as defined on page 39, received at an out-of-network facility will be paid at the higher network level benefit. ⁴ A chart of preventive services is located on Anthem’s website at www.anthem.com. A link to the document is available on the Health and Wellness tab of www.myfirstrewards.com. Click on the Preventive Health Guidelines link under the Medical icon.

Enhanced High Deductible Health Plan (HDHP) The Enhanced HDHP is combination of a high deductible health plan and a tax-advantaged savings account that can be used to pay for medical and prescription drug expenses. Medical benefits are administered by Anthem Blue Cross and Blue Shield. Like the other PPO options, the Enhanced HDHP requires that all care be received from network providers in order to receive a higher level of benefits. Coverage at a reduced level is available from the Enhanced HDHP if care is received out of network. A health savings account is a tax advantaged savings account that can be used to pay current medical and prescription drug expenses as well as to save for future expenses - including retirement. Contributions, earnings and distributions are exempt from federal income and Social Security taxes when used to pay for qualified medical expenses. You own and manage your HSA. Money left in your account at the end of the year rolls over into the next year.




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In-network care is reimbursed at 80% after applicable co-payments and/or a $1,350 annual deductible per covered individual with a maximum family deductible of $2,700. If you elect family coverage (or any coverage level other than single), claims for the entire family will not pay at 80-percent coinsurance until the entire family deductible of $2,700 has been met. This is called a true deductible. After the annual out-of-pocket maximum of $4,500 per person or $9,000 per family for in-network care is reached, the plan will reimburse 100% of eligible expenses. In-network wellness care is covered at 100%. A chart of preventive services is located on Anthem’s website at www.anthem.com. A link to the document is available on the Health and Wellness tab of www.myfirstrewards.com. Click on the Preventive Health Guidelines link under the Medical icon. Care provided outside of the network is reimbursed at 60% of the maximum allowed amount after a $2,500 annual deductible per covered individual and a $5,000 annual family deductible. After the annual out-of-pocket maximum of $8,500 per person or $17,000 per family for out-of-network care is reached, the plan will reimburse 100% of eligible expenses. Benefits for all out-of-network care are subject to a Maximum Allowed Amount set by the administrator. Prescription drug costs apply to the Enhanced HDHP deductibles and out-of-pocket maximums. See the Prescription Drug Summary Plan Description for details. In-network expenses cannot be used to satisfy the out-of-network deductible or out-of-pocket maximum. Likewise, out-of-network expenses cannot be used to satisfy the in-network deductible or applied to the out-of-pocket maximum for in-network care. If you seek out-of-network care, you will be responsible for filing claim forms and for obtaining advance approvals (pre-certification) from the administrator for any inpatient hospital care and outpatient procedures, services, and tests. In addition, when you receive covered services from an out of network provider, you may be responsible for paying any difference between the maximum allowed amount and the provider’s actual charges. You should call a member services representative at the toll-free number shown on your ID card to initiate the pre-certification process. The administrator will gather information from your doctor about your condition and the recommended treatment to determine the level of coverage for the proposed care. Participants in the Enhanced HDHP plan are encouraged to review IRS Publication 969 regarding HSA requirements. The Enhanced HDHP does not contain a preexisting condition limitation.

Summary of the Enhanced HDHP Benefits The following chart provides a summary of the benefits available through the Enhanced HDHP. All covered expenses must be for medically necessary services. All out-of-network care is subject to a Maximum Allowed Amount.

ENHANCED HDHP SUMMARY OF BENEFITS







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Includes prescription drug deductibles and co-pays



















Hospice - Outpatient 80% after deductible 60% after deductible


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Wellness Benefits⁴









¹ All out-of-network care subject to a Maximum Allowed Amount ² You will be responsible for additional $250 co-pay by the carrier if your visit is determined to be non-emergency.

³ Emergency care, as defined on page 39 received at an out-of-network facility will be paid at the higher network level benefit. ⁴ A chart of preventive services is located on Anthem’s website at www.anthem.com. A link to the document is available on the Health and Wellness tab of www.myfirstrewards.com. Click on the Preventive Health Guidelines link under the Medical icon.

Base PPO The Base PPO is administered by Anthem Blue Cross and Blue Shield. Like the other PPO options, the Base PPO requires that all care be received from network providers in order to receive a higher level of benefits. Coverage at a reduced level is available from the Base PPO if care is received out of network. In-network care is reimbursed at 80% after a $750 annual deductible per covered individual with a maximum family deductible of $1,500. After the annual out-of-pocket maximum of $3,500 per person or $7,000 per family for in-network care is reached, the plan will reimburse 100% of eligible expenses. In-network wellness care is covered at 100% with no annual deductible. This benefit coverage is aimed at monitoring your medical status before problems arise. A chart of preventive services is located on




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Anthem’s website at www.anthem.com. A link to the document is available on the Health and Wellness tab of www.myfirstrewards.com. Click on the Preventive Health Guidelines link under the Medical icon. Care provided outside of the network is reimbursed at 60% of the maximum allowed amount after a $1,500 annual deductible per covered individual, with a maximum annual family deductible of $3,000. After the annual out-of-pocket maximum of $6,500 per person or $12,500 per family for out-of-network care is reached, the plan will reimburse 100% of eligible expenses. Benefits for all out-of-network care are subject to a Maximum Allowed Amount set by the administrator. Prescription drug deductibles, co-pays and coinsurance do not apply to the Base PPO deductibles and out-of-pocket maximums. In-network expenses cannot be used to satisfy the out-of-network deductible or out-of-pocket maximum. Likewise, out-of-network expenses cannot be used to satisfy the in-network deductible or applied to the out-of-pocket maximum for in-network care. If you seek out-of-network care, you will be responsible for filing claim forms and for obtaining advance approvals (pre-certification) from the administrator for any inpatient hospital care and outpatient procedures, services, and tests. In addition, when you receive covered services from an out of network provider, you may be responsible for paying any difference between the maximum allowed amount and the provider’s actual charges. You should call a member services representative at the toll-free number shown on your ID card to initiate the pre-certification process. The administrator will gather information from your doctor about your condition and the recommended treatment to determine the level of coverage for the proposed care. The Base PPO does not contain a preexisting condition limitation.

Summary of the Base PPO Benefits The following chart provides a summary of the benefits available through the Base PPO. All covered expenses must be for medically necessary services. All out-of-network care is subject to a Maximum Allowed Amount.

BASE PPO SUMMARY OF BENEFITS














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¹ All out-of-network care subject to a Maximum Allowed Amount ² You will be responsible for additional $250 co-pay by the carrier if your visit is determined to be non-emergency. ³ Emergency care, as defined on page 39, received at an out-of-network facility will be paid at the higher network level benefit.

⁴ Since Wellness Benefits are covered at 100% with no deductible or coinsurance, expenses incurred for wellness care are not deducted from the HRA ⁴ A chart of preventive services is located on Anthem’s website at www.anthem.com. A link to the document is available on the Health and Wellness tab of www.myfirstrewards.com. Click on the Preventive Health Guidelines link under the Medical icon.

Medicare Preferred (LPPO) Base Plan The LPPO Base Plan is a retiree plan that is administered by Anthem Blue Cross and Blue Shield. The LPPO Base Plan is a Medicare Preferred Plan that is offered by Anthem as a replacement to the traditional Medicare program. Participants must be enrolled in both Medicare Part A & Part B to be eligible to enroll into a LPPO plan. Participants in the plan can visit any hospital or physician that accepts Medicare Assignment and the terms of the Medicare Preferred LPPO plan. Participants present their Anthem Blue Cross and Blue Shield Medicare Preferred LPPO card when receiving services. Anthem Blue Cross and Blue Shield will pay the physician/hospital for the eligible charges. Eligible charges and co-pays are listed in the table below. Participants can decrease co-payment amounts by calling Anthem Blue Cross and Blue Shield to pre-notify them when inpatient hospital services, durable medical equipment or home health care services have been scheduled. The LPPO Base plan has a $200 annual deductible. The annual out-of-pocket maximum is $5,000 per individual combined in- and out-of-network care. After the annual out-of-pocket maximum is reached, the plan will reimburse 100% of eligible expenses. LPPO plans do not have a maximum lifetime benefit for medical coverage. Refer to your LPPO Evidence of Coverage (EOC) booklet provided by Anthem for




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detailed benefit information. Should there be any discrepancy between benefits outlined in this document and benefits outlined in the LPPO EOC, the LPPO EOC shall govern.

ANTHEM BLUE CROSS and BLUE SHIELD LPPO BASE PLAN

Plan Feature LPPO Base Annual Medical Deductible $200 Annual Out-of-Pocket Maximum $5,000 per individual Lifetime Maximum No Limit

Inpatient Hospital Care

$750 co-pay per admission $2,250 In and Out of Network combined Maximum out of pocket combined with IP Mental Health

Emergency Room $75 co-pay; No co-pay if admitted within 72 hours, deductible does not apply

Mental Health/Substance Abuse Services

$750 co-pay per admission $2,250 In and Out of Network combined Maximum out of pocket combined with IP Hospital Care

Skilled Nursing Facility $0 copay days 1-20; $25 copay days 21-100 Hospice Must use Medicare certified hospice Paid by original Medicare

Outpatient Surgery $200 co-pay, after deductible Urgent Care Visit $35 co-pay Emergency - Ambulance $100 co-pay, deductible does not apply Physical, Occupational, Speech Therapy $35 co-pay, after deductible Chiropractic Visit $20 co-pay, after deductible

Durable Medical Equipment (DME) Responsible for 10% coinsurance on all Medicare-approved DME

Cardiac Rehab $35 co-pay, after deductible Home Health Care No co-pay

Allergy Testing $0 copay Medicare-covered testing after deductible

Allergy Injections $0 copay Medicare-covered allergy injections after deductible

Primary Care Office Visit $20 co-pay, after deductible Specialist Office Visit $35 co-pay


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X-Ray and Laboratory

$35 co-pay, after deductible No co-pay for Lab tests Complex Diagnostic Tests and Radiology $100 co-pay after deductible

Mental Health/Substance Abuse Professional Visit

$35 co-pay for mental health $35 co-pay for substance abuse

Routine Physical Exam 1 exam every 12 months No co-pay

Routine Gynecological Exam No co-pay Routine Mammography 1 mammogram every 12 months No co-pay

Routine Colonoscopy Screening No co-pay Well Baby/Child Care Visit Not covered Immunizations (Medicare Part B) No co-pay Routine Prostate Screening No co-pay Routine Eye Exam No co-pay, maximum $50 benefit per year Abnormal Aortic Aneurysm Screening No co-pay Smoking Cessation Counseling No co-pay, visit limits apply

Your Member ID Card Once you’ve enrolled in one of the medical plans, you will receive an ID card. Carry your ID card with you and have it available whenever you make an appointment or receive medical services. The card also gives you and your medical provider, your group number, payment information, and the toll-free number for member services. You should make a note of the member services number on your ID card. If your card is lost or stolen, you will need to call member services to request a replacement card. You can also request a member ID card by logging into to Anthem’s website at www.Anthem.com.

Member Services When you have questions about your coverage, claim status, or an explanation of benefit form, a member services representative is available to help you. Call the toll-free number shown on your ID card or log-in at www.Anthem.com

Mental Health and Chemical Dependency Care Each of the plans provides coverage for inpatient and outpatient treatment of mental health and chemical dependency conditions.

Life Resources (Employee Assistance Program) Active employees should first contact the Life Resources Program (EAP) before seeking mental health or chemical dependency care through the medical plan. Life Resources (EAP) provides up to five outpatient visits for treatment of a mental health or chemical dependency conditions at no charge to you. If further care is required after the five outpatient visits have been used, you may seek care through the Plan.




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The Life Resources Program (EAP) provides assistance for many other circumstances that may affect you and your household members. For more information, refer to the Work/Life Employee Assistance Plan section of the Compensation and Benefits Handbook, or contact Life Resources at 1-888-745-0714 or www.firstenergycorp.com/liferesources

PROGRAMS OFFERED BY THE HEALTH CARE PLAN The following programs are administered by Anthem Blue Cross Blue Shield to assist you with your health care decisions.

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

AIM Imaging Cost & Quality Program This Imaging Cost & Quality Program is administered by AIM Specialty Health (1-888-953-6703). This Program provides you with access to important information about imaging services you might need. If you need an MRI or a CT scan, it’s important to know that costs can vary quite a bit depending on where you go to receive the service. Sometimes the differences are significant – anywhere from $300 to $3000 – but a higher price doesn’t guarantee higher quality. When you are required to pay a portion of this cost (like a deductible or coinsurance) where you go can make a very big difference to your wallet. That’s where the AIM Imaging Cost & Quality Program comes in – AIM does the research for you and makes it available to help you find the right location for your MRI or CT scan. Here’s how the Program works: • Your doctor refers you to a radiology provider for an MRI or CT scan • AIM works with your doctor to help make sure that you are receiving the right test – using evidence-

based guidelines • AIM also reviews the referral to see if there are other providers in your area that are high quality but

have a lower price than the one you were referred to • If AIM finds another provider that meets the quality and price criteria, AIM will give you a call to let

you know • You have the choice – you can see the radiology provider your doctor suggested OR you can choose to

see a provider that AIM tells you about. AIM will even help you schedule an appointment with the new provider

The AIM Imaging Cost & Quality Program gives you the opportunity to reduce your health care expenses by selecting high quality, lower cost providers or locations. We are bringing this Program to you to give you information that helps you to make informed choices about where to go when you need care.

24/7 NurseLine You may have emergencies or questions for nurses around-the-clock. 24/7 NurseLine (1-800-700-9184) provides you with accurate health information any time of the day or night. Through one-on-one counseling with experienced nurses available 24 hours a day via a convenient toll-free number, You can make more


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informed decisions about the most appropriate and cost-effective use of health care services. A staff of experienced nurses is trained to address common health care concerns such as medical triage, education, access to health care, diet, social/family dynamics and mental health issues. Specifically, the 24/7 NurseLine features: • A skilled clinical team – RN license (BSN preferred) that helps you assess systems, understand medical

conditions, ensure you receive the right care in the right setting and refer you to programs and tools appropriate to your condition.

• Bilingual RNs, language line and hearing impaired services. • Access to the AudioHealth Library, containing hundreds of audiotapes on a wide variety of health topics. • Proactive callbacks within 24 to 48 hours in the event you are referred to 911 emergency services, poison

control and pediatric patients with needs identified as either emergent or urgent. • Referrals to relevant community resources.

Future Moms The Future Moms program (1-800-828-5891) offers a guided course of care and treatment, leading to overall healthier outcomes for mothers and their newborns. Future Moms helps routine to high-risk expectant mothers focus on early prenatal interventions, risk assessments and education. The program includes special management emphasis for expectant mothers at highest risk for premature birth or other serious maternal issues. The program consists of nurse coaches, supported by pharmacists, registered dietitians, social workers and medical directors. You’ll get:

• 24/7 phone access to a nurse coach who can talk with you about your pregnancy and answer your questions.

• Your Pregnancy Week by Week, a book to show you what changes you can expect for you and your baby over the next nine months.

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

• The Future Moms program is not offered to retirees.

LiveHealth Online When available in your area, your coverage will include online visits from a LiveHealth Online Provider. Covered services include a medical consultation using the internet via a webcam, chat or voice. Online visit charge will be billed to Anthem and Deductible and Coinsurance will be applied to the claim, Online visits are not covered from Providers other than those contracted with LiveHealth Online. Non Covered Services include, but are not limited to communications used for:

• Reporting normal lab or other test results • Office appointment requests • Billing, insurance coverage or payment questions • Requests for referrals to doctors outside the online care panel • Benefit precertification • Physician to Physician consultations

Health Care Management Health Care Management (1-866-776-4793) includes the processes of Precertification, Predetermination and Post Service Clinical Claims Review. Its purpose is to promote the delivery of cost-effective medical care by reviewing the use of appropriate procedures, setting (place of service), and resources and optimizing your health. These processes are described in the following section.


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Network Providers know that in many cases you are required to obtain prior authorization in order for you to receive benefits for certain services. However, it is ultimately your responsibility to work with your provider to take the necessary steps. If you have any questions regarding the types of service that require precertification or any information contained in this section you should call the Anthem Customer Service telephone number on your Identification Card.

Medical Specialty Drugs Administered by a Medical Provider The Plan covers specialty drugs that must be administered to you by a healthcare professional when they are covered services. Examples of this might be chemotherapy, infused drugs, and certain types of injections. Specialty drugs that a patient can self-administer or a care-giver can administer are not covered under the medical plan. Examples of this might be oral, inhaled, topical or certain types of self-administered injections. Specialty drugs that you can obtain from a retail or mail order pharmacy are also not covered under the medical plan. Refer to the Prescription Drug Summary Plan Description for coverage of these specialty drugs. Precertification is required for certain provider administered medical specialty drugs. Your provider will submit clinical information to Anthem which will be reviewed. Anthem will communicate their decision to both you and your provider in writing. Make sure your provider has the Medical Specialty Rx toll free number (1-888-953-6703) located on the back of your ID card.

Voluntary Site of Care Redirection Program Infused specialty drugs are used to treat very specific health conditions and are often given by injection or infusion. You may have the option to receive these treatments from the comfort of your home or at an infusion suite rather than going to the hospital or outpatient clinic. Anthem has partnered with a specialty pharmacy provider to offer this voluntary site of care program to you. If you are receiving infusion therapy, you may receive notification in the mail and by phone about your options. If you choose to participate, a representative will work directly with you and your doctor to coordinate your next treatment. You may not only save time and money, you may have the option to schedule your treatments after-hours or on weekends at your convenience. Participation in this program is voluntary. For more information, contact Anthem Member Services at 1-866-236-4365. This number is also on the back of your ID card.

Types of Requests Precertification – A required review of a service, treatment or admission for a benefit coverage determination which must be obtained prior to the service, treatment or admission start date. For emergency admissions, you, your authorized representative or physician must notify the Claims Administrator within 2 business days after the admission or as soon as possible within a reasonable period of time. For childbirth admissions, Precertification is not required unless there is a complication and/or the mother and baby are not discharged at the same time. Predetermination – An optional, voluntary Prospective or Concurrent request for a benefit coverage determination for a service or treatment. The Claims Administrator will review to determine if there is an exclusion for the service or treatment. If there is a related clinical coverage guideline, the benefit coverage


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review will include a review to determine whether the service meets the definition of Medical Necessity under this Plan or is Experimental/Investigative as that term is defined in this Plan. Post Service Clinical Claims Review A retrospective review for a benefit coverage determination to determine the medical necessity or experimental/investigative nature of a service, treatment or admission that did not require Precertification and did not have a Predetermination review performed. Medical Reviews occur for a service, treatment or admission in which the Claims Administrator has a related clinical coverage guideline and are typically initiated by the Claims Administrator.

SERVICES COVERED BY THE HEALTH CARE PLAN The types of services covered by the Plan are described here.

Hospital Benefits Hospital room and board and other services are paid by the plans when a covered person is admitted for an illness or injury that is not work related.

Room and Board Room and board expenses are based upon the hospital’s usual daily rate for semi-private room accommodations. Unless medically necessary, payment for private room and board charges will be limited to the hospital’s usual daily rate for semi-private room accommodations. If a hospital does not have semi-private rooms, the daily limit will be an amount equal to the average daily charge for its least expensive private room.

Other Hospital Services and Supplies During the period room and board expenses are covered, or during an outpatient visit for surgery, charges for necessary hospital services and supplies will be covered. Some examples are:

• General nursing care, excluding private or special nurses; • Use of operating, cast and cystoscopic room and equipment; • Use of recovery room, treatment room and equipment; • Use of intensive care room, treatment and equipment; • Use of anesthesia supplies and equipment, and administration of anesthesia by a hospital

employee; • Laboratory examinations and pathological tissue examinations; • X-ray examinations and therapy; • All drugs and medicines for use in the hospital that are commercially available for purchase

and readily obtainable by the hospital; • Use of blood transfusion equipment (not including blood or blood plasma); administration of

blood; • Use of oxygen and equipment for its administration; • Dressings and plaster casts; • Use of therapeutic equipment; • Ambulance provided by the hospital or any local ambulance service required for initial

transfer to the closest hospital capable of providing the required care.


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All other regular and necessary daily supplies and services, other than professional services.

Doctor’s Hospital Visits The plans cover doctor’s visits during a hospital stay that results in a room and board charge. The hospital stay must be due to an illness or injury that is not work related.

Newborn Care The plans cover hospital room and board, doctor’s visits and other hospital services and supplies furnished for the care of a newborn child immediately following birth. Newborn charges for the child of a dependent child are not covered under the Plan. Hospital benefits resulting from pregnancy are determined in the same manner as any other condition. Group health plans and health insurance providers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with child birth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the Plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Emergency Admissions Admission to the hospital because of an emergency is covered the same as any other illness or injury.

Hospital Expenses Not Covered Except for outpatient confinements for preadmission testing, benefits are not provided for confinements solely for radiographic, laboratory or basal metabolism examinations, electroencephalograms, electrocardiograms, physical therapy, radio-therapy or any combination of such services.

Covered Surgical Benefits Benefits will be provided for:

• Surgical services performed by a doctor as the result of an illness or injury that is not work related;

• Coverage for a mastectomy, which includes reconstruction of the breast on which the mastectomy was performed – including surgery and reconstruction of the other breast to present a symmetrical appearance – and prostheses and coverage for physical complications throughout the mastectomy procedure, including lymphedemas;

• Obstetrical services resulting from pregnancy are covered in the same manner as any other condition. Charges related to the newborn child of a dependent child are not covered under the Plan;

• Surgical services for artificial insemination; • Surgical services for up to 3 attempts of invitro fertilization, only after all other methods of

fertilization have been exhausted;


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• The administration of anesthetics, except local infiltration anesthetic, provided that the anesthesia is administered and billed by a doctor other than the operating surgeon or surgical assistant;

• Services of a doctor who actively assists the operating surgeon if the condition of the patient requires such assistance, and the hospital does not have surgical assistance available;

• The immediate preoperative examination by the doctor performing the procedure and the postoperative care required by the procedure.

Outpatient Surgery Many kinds of surgery are performed without a hospital stay. You may be instructed by your physician to go to the outpatient department of a hospital or surgical center on the day surgery is to be performed. If you have any surgical procedure performed on an outpatient basis, the plans will cover the surgery, including fees for the surgeon, assistant surgeon (if medically necessary) and anesthesiologist, in addition to laboratory, x-rays, supplies and facility charges.

OTHER BENEFITS

Preadmission Testing The plans cover preadmission laboratory tests and x-rays performed on an outpatient basis before a scheduled hospital admission or outpatient surgery. The following conditions must be met:

• The hospital admission or outpatient surgery must be ordered and certified before the tests are performed;

• The tests should not be diagnostic in nature or used to determine the patient’s condition or the necessity for surgery;

• Hospital admission or outpatient surgery must follow your tests within 7 days; • Tests may not be duplicated upon admission unless medically necessary.

Emergency Care Emergency care is defined as care given in a hospital's emergency room to evaluate and treat medical conditions of a recent onset and severity, including, but not limited to, severe pain, which would lead a prudent layperson possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in:

• placing the person's health in serious jeopardy; or • serious impairment to bodily functions; or • serious dysfunction of a body part or organ; or • in the case of a pregnant woman, serious jeopardy to the health of the fetus.

Examples include unconsciousness, severe difficulty breathing, poisoning, heart attack and serious bleeding. If you have a true emergency, as defined above, seek medical attention immediately. If emergency services are received at an out-of-network facility, charges related to this visit will be covered at the higher network level of benefit, provided that the emergency criteria outlined above is met. However, when you receive


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covered services from an out of network provider, you may be responsible for paying any difference between the maximum allowed amount and the provider’s actual charges. If you go to the emergency room for a non-emergency situation, the services may not be covered because the level of care may not be medically necessary. You will be responsible for an additional $250 copay by the carrier if your visit is determined to be a non-emergency (not applicable to Medicare Preferred Base LPPO Plan).

Obstetrical Care Obstetrical care resulting from pregnancy is covered in the same manner as any other condition. Charges related to the newborn child of a dependent child are not covered under the Plan

Out-Of-Area Care If you are away from home and require medical care, contact member services to determine if there are network providers in the area. Coverage extends to eligible dependent children who are away at school. If your child has a medical emergency while away at school, he or she should seek appropriate care at the nearest hospital or source of medical care. Any routine, non-emergency, or follow-up care should be provided within the network whenever possible. Contact member services to determine if there are network providers in the area.

Doctor’s Office and Home Visits The plans cover visits made by you or your dependents to a doctor’s office or visits made by a doctor to your home for treatment of an illness or injury which is not work related.

Wellness Benefits The plans cover benefits for routine care provided by an in-network physician to monitor your medical status in order to identify problems before they arise. Wellness care is covered at 100% with no annual deductible when received from a network medical provider. A chart of preventive services is located on Anthem’s website at www.anthem.com. A link to the document is available on the Health and Wellness tab of www.myfirstrewards.com. Click on the Preventive Health Guidelines link under the Medical icon Further care required as the result of the wellness exam, lab work or testing is subject to the deductible and percentage reimbursement (coinsurance) based on the plan you have selected. Treatment must be received in-network in order to receive the higher level of benefits from any of the PPO plans. Wellness care received outside the PPO network is not covered by the Plans.

Routine Gynecological Exams and Mammograms Female employees and the female dependents of employees, including dependent children, may receive one routine gynecological exam each calendar year from any participating network provider as part of wellness care. The plan covers the exam, pap smear and any related lab fees. Your gynecologist or physician may also recommend a mammogram if appropriate. Mammograms must be received from a participating network provider to be covered by the plans. Routine gynecological care and mammograms will not be covered if received outside the PPO network.




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Further care required as the result of gynecological exam, or mammogram is subject to the deductible and percentage reimbursement (coinsurance) based on the plan you have selected. Treatment must be received in-network in order to receive the higher level of benefits from any of the plans.

Outpatient Short-Term Rehabilitation including Physical Therapy, Radiotherapy and Speech Therapy The plans cover eligible expenses for outpatient physiotherapy, radiotherapy and speech therapy for treatment of an illness or injury which is not work related when ordered by a physician or a licensed certified physical, occupational or speech therapist. Short-term rehabilitation is therapy which is expected to result in the improvement of a body function (including the restoration of the level of an existing speech function), which has been lost or impaired due to an injury, disease or congenital defect. Short-term rehabilitation services consist of physical therapy, occupational therapy, radiotherapy or speech therapy furnished to a person who is not confined as an inpatient in a hospital or other facility for medical care. This therapy shall be expected to result in significant improvement of the person's condition. Short-Term Rehabilitation Services Not Covered Include:

• Special education, including lessons in sign language, to instruct a person whose ability to speak has been lost or impaired to function without that ability;

• Speech therapy unless necessary to restore speech which was lost due to disease, injury, or as the result of a congenital defect.

Outpatient Diagnostic X-rays and Lab Exams The plans cover diagnostic x-ray and laboratory examinations necessary because of a diagnosed illness or injury which is not work related. Diagnostic x-rays and lab exams received as part of care for a diagnosed illness or injury are not wellness care and are subject to the deductible and percentage reimbursement (coinsurance) based on the plan you have elected.

Treatment of Mouth Conditions The plans cover doctor’s services for treatment of a tumor involving the teeth, surrounding tissue or structure; or for the treatment of injuries to natural teeth the calendar year of the injury or the next one, including the replacement of the teeth within that period.

Miscellaneous Services and Supplies The plans provide benefits for other miscellaneous services and supplies for treatment of an illness or injury which is not work related. The following are examples of other eligible expenses covered by the plans: ♦ Blood and blood plasma; ♦ Prosthetic devices such as artificial limbs, larynx and eyes; ♦ Durable medical equipment including surgical dressings, casts, splints, trusses, braces, crutches,

rental of wheelchair or hospital bed, oxygen and rental of equipment for its administration (subject to pre-certification through member services);

♦ X-ray and radioactive treatments and treatments with other radioactive substances; ♦ Private duty nursing by a registered graduate nurse (maximum 15 days per calendar year, subject to

pre-certification through member services).


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Mental Health and Chemical Dependency Benefits The plans provide benefits for inpatient treatment of psychiatric, mental and nervous disorders. Inpatient treatment for drug or alcohol dependency or abuse is also covered. These benefits are provided the same as any other hospital stay. The plans cover counseling and other medically necessary services and supplies. Coverage is also available for outpatient psychiatric care and chemical dependency treatment. Referral services are available through member services to provide access to a network of providers. There is no lifetime maximum for any medical care, including mental health benefits. This applies to both inpatient and outpatient care combined. There is also no lifetime maximum for chemical dependency benefits, applicable to both inpatient and outpatient care combined.

EXTENDED CARE SERVICES

Home Health Care In cases where intermediate care and monitoring is medically necessary, the plans cover home health care as an alternative to extended hospitalization or confinement in a convalescent care facility. The plans cover a maximum of 100 visits per calendar year up to 50% of the cost of a semi-private room. Each visit of up to 4 hours by a home health aide is one visit, and each visit by a nurse or therapist is considered one visit. The provider of the home health care services must be a licensed agency or organization and meet all the following requirements: ♦ Have a full-time administrator; ♦ Maintain written records of services provided to the patient; ♦ Include on its staff one registered nurse (R.N.). The home health care program for care and treatment in your home of an illness or injury must be prescribed in writing by your doctor and is subject to pre-certification by member services. The following, when performed by someone other than a family member, are considered eligible services: ♦ Home nursing care rendered or supervised by a registered nurse (R.N.); ♦ Home health aide services; ♦ Physical, occupational, speech or respiratory therapy by a qualified therapist; ♦ Nutrition counseling provided or supervised by a registered dietitian; ♦ Medical supplies, laboratory services, drugs and medications prescribed by a physician are also covered

when provided in your home.

Convalescent Care Following a hospital stay, you or your covered dependents may need more closely monitored care than home health care services can provide. A convalescent care facility provides round-the-clock professional care without the expense of a full-service hospital. Subject to pre-certification, the plans cover convalescent care facilities for you and your eligible dependents if the confinement is recommended by your physician and begins within 14 days after discharge from a hospital confinement that lasted at least three days. A maximum of 60 days is covered and begins with the first day the person is confined in a convalescent facility and ends when the person has not been confined in a hospital, convalescent facility, or other place giving nursing care for 90 consecutive days.


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The plans do not cover room and board charges, or other services and supplies provided solely for custodial care in a rest home, nursing facility or a facility for the aged.

Hospice Care The plans cover the following benefits for hospice care for a terminally ill person: ♦ Inpatient care for room and board and other services and supplies furnished to a patient for pain control

and other acute and chronic symptom management. The plans cover a maximum of 30 days of inpatient care up to 50% of the cost of a semi-private room.

♦ Outpatient charges for part-time or intermittent nursing care by an R.N. or L.P.N. for up to 8 hours in any one day;

♦ Medical social services under the direction of a physician. These include assessment of the person’s social, emotional and medical needs, and the home and family situation; identification of the community resources which are available to the person; and assisting the person to obtain those resources needed to meet the person’s assessed needs.

♦ Psychological and dietary counseling; ♦ Consultation or case management services by a physician; ♦ Physical and occupational therapy; ♦ Part-time and intermittent home health aide services for up to 8 hours in any one day. The following charges are not covered under hospice care: ♦ Bereavement counseling or pastoral counseling; ♦ Funeral arrangements; ♦ Financial or legal counseling, including estate planning or drafting a will; ♦ Homemaker or caretaker services; ♦ Respite care.

Vision Care All participants in the FirstEnergy Health Care Plan receive basic vision care through the FirstEnergy Vision Plan which is a separate plan whose terms can be found in the FirstEnergy Vision Plan SPD. Under the basic vision coverage, available at no cost as part, you may receive discounts on your examination, lenses and frames at participating providers. For a listing of current providers contact the contracted administrator - Vision Service Plan at (800) 877-7195 or go to the VSP Web Site at www.vsp.com.

What the Health Care Plan Does Not Cover ♦ Anything that is determined not to be necessary for the treatment of disease or injury; ♦ Anything not ordered by a doctor or not necessary for medical care; ♦ Expenses used to satisfy the deductible (Except HRA and HSA reimbursements applied to the

deductible); ♦ Any hospital stay or other services and supplies furnished before a person is covered under the Plan; ♦ The portion of out-of-network charges in excess of the Maximum Allowed Amount; ♦ Expenses due to cosmetic surgery, except when due to an accident occurring while covered under the

Plan; ♦ Experimental procedures that generally are not accepted by the medical profession; ♦ Care received that is educational in nature or for research purposes;

http://www.vsp.com/


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♦ Periodic physical checkups and routine examinations unless performed by your physician; ♦ Tests for non-diagnostic purposes; ♦ Expenses due to an accident related to employment or sickness covered under Workers’ Compensation

or similar law; ♦ Services or supplies furnished by or for the U.S. Government or any other government, unless payment

is legally required; or to the extent provided under any governmental plan or law under which the individual is, or could be, covered;

♦ Services or supplies received as a result of an act of war occurring while covered; ♦ Doctors’ services or x-rays in connection with the treatment of periodontal or periapical disease or any

condition, other than a tumor, involving teeth, surrounding tissue or structure; ♦ Speech therapy unless necessary to restore speech which was lost due to disease, injury, or as the

result of a congenital defect; ♦ Prescription medication unless provided as part of inpatient hospital care or outpatient surgery covered

by the plan; ♦ Vision examinations (except under the Medicare Preferred Plan), glasses, frames, lenses, contacts, or

surgical procedures to correct vision; ♦ Hearing aids; ♦ Routine foot care, Shoe inserts, orthotics (except when prescribed by a physician for diseases of the

foot or systemic diseases that affect the foot such as diabetes when deemed medically necessary), and orthopedic shoes (except when an orthopedic shoe is joined to a brace).

♦ Dental care and treatment and oral surgery (by Physicians or dentists) including dental surgery; surgical removal of impacted teeth; dental appliances; dental prostheses such as crowns, bridges, or dentures; implants; orthodontic care; operative restoration of teeth (fillings); dental extractions; endodontic care; apicoectomies; excision of radicular cysts or granuloma; treatment of dental caries, gingivitis, or periodontal disease by gingivectomies or other periodontal surgery; vestibulopathies; alveoplasties; dental procedures involving teeth and their bone or tissue supporting structures; frenulectomy. Any treatment of teeth, gums or tooth related service. (Related outpatient facility services are covered when necessary to ensure the safety of the patient, Inpatient would be subject to precertification.)

♦ Nursing, speech therapy, physical therapy or psychotherapy you provide or provided by your spouse, dependent or relative;

♦ Hospital charges to the extent they are allocable to scholastic education or vocational training: ♦ Charges for services provided to the newborn child of a dependent child are not covered under the Plan.

If you have questions about your coverage, contact Anthem Blue Cross and Blue Shield member services. The number is located on the back of your medical card.

Definition of Terms Definition of terms in the Plan terms are used which have special meanings. A hospital is a legally operated institution which provides complete inpatient services and surgical facilities for a fee under the supervision of a staff and physicians, and nursing service by registered graduate nurses. The term does not include an institution, or part of one, which is used principally as a rest or nursing facility, or facility for the aged.


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A doctor is a licensed practitioner of the healing arts acting within the scope of his/her practice. The term includes a Doctor of Medicine (M.D.), a Doctor of Osteopathy (D.O.), a Chiropractor (D.C.), a Podiatrist (D.P.M.), a Doctor of Dental Surgery (D.D.S.) and licensed Psychologists. A convalescent care facility is a place that is licensed, organized and operated to provide convalescent and rehabilitative treatment and which: ♦ Provides skilled nursing care for patients who require medical or nursing care or provides rehabilitation of injured or sick persons; ♦ Has policies to guide its operations; ♦ Has a medical staff; ♦ Has a requirement that the care of every patient must be under the supervision of a doctor, and that a

physician be available to furnish necessary medical care in case of an emergency; ♦ Meets nursing needs on a 24-hour basis, and has at least one registered professional nurse employed

full time; ♦ Maintains medical records on all patients; ♦ Provides methods and procedures for giving out drugs to its patients; ♦ Has a program whereby admissions, length of stay and services are reviewed for their necessity and

efficiency; ♦ Is licensed under state or local law or is approved by the appropriate state or local agency. The term convalescent care facility does not include a rest home, nursing home, place for custodial care or facility for the aged. The Plan only covers necessary services and supplies and well-patient care provided by your physician. Services and supplies are necessary if they are needed for the diagnosis, care, or treatment of a physical condition. In addition, based upon recognized standards of the specialty involved, the service or supply must be widely accepted as effective, appropriate, and essential. Services and supplies will not be considered necessary if they are rendered by a professional but do not require the technical skills of the provider. Also, services and supplies will not be considered necessary if they are provided mainly as a convenience, or if they are provided on an inpatient basis to an individual who’s physical and mental condition does not require confinement.

Inter-Plan Arrangements

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


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When you receive care outside of the Anthem Service Area, you will receive it from one of two kinds of Providers. Most Providers (“participating providers”) contract with the local Blue Cross and/or Blue Shield Plan in that geographic area (“Host Blue”). Some Providers (“nonparticipating providers”) don’t contract with the Host Blue. Below is how pay both kinds of Providers are paid.

Inter-Plan Arrangements Eligibility – Claim Types Most claim types are eligible to be processed through Inter-Plan Arrangements, as described above. Examples of claims that are not included are Prescription Drugs that you obtain from a Pharmacy and most dental or vision benefits. A. BlueCard® Program Under the BlueCard® Program, when you receive Covered Services within the geographic area served by a Host Blue, the Claims Administrator will still fulfill its contractual obligations. But, the Host Blue is responsible for: (a) contracting with its Providers; and (b) handling its interactions with those Providers. When you receive Covered Services outside the Anthem Service Area and the claim is processed through the BlueCard Program, the amount you pay is calculated based on the lower of: 1. The billed charges for Covered Services; or 2. The negotiated price that the Host Blue makes available to the Claims Administrator. Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to the Provider. Sometimes, it is an estimated price that takes into account special arrangements with that Provider. Sometimes, such an arrangement may be an average price, based on a discount that results in expected average savings for services provided by similar types of Providers. Estimated and average pricing arrangements may also involve types of settlements, incentive payments and/or other credits or charges. Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price the Plan used for your claim because they will not be applied after a claim has already been paid.

B. Negotiated (non–BlueCard Program) Arrangements With respect to one or more Host Blues, instead of using the BlueCard Program, Anthem may process Your claims for Covered Services through Negotiated Arrangements for National Accounts. The amount you pay for Covered Services under this arrangement will be calculated based on the lower of either billed charges for Covered Services or the negotiated price (refer to the description of negotiated price under Section A. BlueCard Program) made available to Anthem by the Host Blue.

C. Special Cases: Value-Based Programs If You receive Covered Services under a Value-Based Program inside a Host Blue’s Service Area, you will not be responsible for paying any of the Provider Incentives, risk-sharing, and/or Care Coordinator Fees that are a part of such an arrangement, except when a Host Blue passes these fees to Anthem through average pricing or fee schedule adjustments. Additional information is available upon request. Value-Based Programs: Negotiated (non–BlueCard Program) Arrangements If Anthem has entered into a Negotiated Arrangement with a Host Blue to provide Value-Based Programs to the Employer on your behalf, Anthem will follow the same procedures for Value-Based Programs administration and Care Coordinator Fees as noted above for the BlueCard Program.


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D. Inter-Plan Programs: Federal/State Taxes/Surcharges/Fees Federal or state laws or regulations may require a surcharge, tax or other fee. If applicable, the Plan will include any such surcharge, tax or other fee as part of the claim charge passed on to you.

E. Nonparticipating Providers Outside the Claims Administrator’s Service Area Allowed Amounts and Member Liability Calculation When Covered Services are provided outside of Anthem’s Service Area by non-participating providers, the Plan may determine benefits and make payment based on pricing from either the Host Blue or the pricing arrangements required by applicable state or federal law. In these situations, the amount you pay for such services as Deductible or Coinsurance will be based on that allowed amount. Also, you may be responsible for the difference between the amount that the non-participating provider bills and the payment the Plan will make for the Covered Services as set forth in this paragraph. Federal or state law, as applicable, will govern payments for out-of-network Emergency services. Exceptions In certain situations, the Plan may use other pricing methods, such as billed charges or the pricing the Plan would use if the healthcare services had been obtained within the Anthem Service Area, or a special negotiated price to determine the amount the Plan will pay for services provided by nonparticipating providers. In these situations, you may be liable for the difference between the amount that the nonparticipating provider bills and the payment the Plan make for the Covered Services as set forth in this paragraph.

F. Blue Cross Blue Shield Global Core ® Program If You plan to travel outside the United States, call Member Services to find out Your Blue Cross Blue Shield Global Core benefits. Benefits for services received outside of the United States may be different from services received in the United States. Remember to take an up to date health ID card with you. When You are traveling abroad and need medical care, you can call the Blue Cross Blue Shield Global Core Service Center any time. They are available 24 hours a day, seven days a week. The toll-free number is 800-810-2583. Or you can call them collect at 804-673-1177. If You need inpatient hospital care, you or someone on your behalf, should contact the Claims Administrator for preauthorization. Keep in mind, if you need Emergency medical care, go to the nearest hospital. There is no need to call before you receive care.

How Claims are Paid with Blue Cross Blue Shield Global Core In most cases, when you arrange inpatient hospital care with Blue Cross Blue Shield Global Core, claims will be filed for you. The only amounts that you may need to pay up front are any coinsurance or deductible amounts that may apply. You will typically need to pay for the following services up front:

• Doctors services; • Inpatient hospital care not arranged through BlueCard Worldwide; and • Outpatient services.

You will need to file a claim form for any payments made up front.


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When you need Blue Cross Blue Shield Global Core claim forms you can get international claims forms in the following ways:

• Call the Blue Cross Blue Shield Global Core Service Center at the numbers above; or • Online at www.bcbsglobalcore.com.

You will find the address for mailing the claim on the form.

Assignment You authorize the Claims Administrator, on behalf of the Plan, to make payments directly to Providers for Covered Services. The Claims Administrator also reserves the right to make payments directly to you. Payments may also be made to, and notice regarding the receipt and/or adjudication of claims, an alternate recipient, or that person’s custodial parent or designated representative. Any payments made by the Claims Administrator will discharge the Plan’s obligation to pay for Covered Services. You cannot assign Your right to receive payment to anyone else, except as required by a “Qualified Medical Child Support Order” as defined by ERISA or any applicable Federal law. Once a Provider performs a Covered Service, the Claims Administrator will not honor a request to withhold payment of the claims submitted. The coverage and any benefits under the Plan are not assignable by any member without the written consent of the Plan, except as provided above.

Maximum Allowed Amount General This section describes how the Claims Administrator determines the amount of reimbursement for Covered Services. Reimbursement for services rendered by Network and Out-of-Network Providers is based on this Plan’s Maximum Allowed Amount for the Covered Service that you receive. Please see the Inter-Plan Arrangements section for additional information.

• The Maximum Allowed Amount for this Plan is the maximum amount of reimbursement Anthem will allow for services and supplies:that meet our definition of Covered Services, to the extent such services and supplies are covered under the Plan and are not excluded;

• that are Medically Necessary; and • that are provided in accordance with all applicable preauthorization, utilization management or

other requirements set forth in the Plan. You will be required to pay a portion of the Maximum Allowed Amount to the extent you have not met your Deductible or Coinsurance. In addition, when you receive Covered Services from an Out-of-Network Provider, you may be responsible for paying any difference between the Maximum Allowed Amount and the Provider’s actual charges. This amount can be significant. When you receive Covered Services from a Provider, the Claims Administrator will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect the Claims Administrator’s determination of the Maximum Allowed Amount. The Claims Administrator’s application of these rules does not mean that the Covered Services you received were not Medically Necessary. It


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means the Claims Administrator has determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed. When this occurs, the Maximum Allowed Amount will be based on the single procedure code rather than a separate Maximum Allowed Amount for each billed code. Likewise, when multiple procedures are performed on the same day by the same Physician or other healthcare professional, the Plan may reduce the Maximum Allowed Amounts for those secondary and subsequent procedures because reimbursement at 100% of the Maximum Allowed Amount for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive.

Provider Network Status The Maximum Allowed Amount may vary depending upon whether the Provider is a Network Provider or an Out-of-Network Provider. A Network Provider is a Provider who is in the managed network for this specific product or in a special Center of Excellence or other closely managed specialty network, or who has a participation contract with the Claims Administrator. For Covered Services performed by a Network Provider, the Maximum Allowed Amount for this Plan is the rate the Provider has agreed with the Claims Administrator to accept as reimbursement for the Covered Services. Because Network Providers have agreed to accept the Maximum Allowed Amount as payment in full for those Covered Services, they should not send you a bill or collect for amounts above the Maximum Allowed Amount. However, you may receive a bill or be asked to pay all or a portion of the Maximum Allowed Amount to the extent you have not met your Deductible or have Coinsurance. Please call Customer Service for help in finding a Network Provider or visit www.anthem.com. Providers who have not signed any contract with the Claims Administrator and are not in any of the Claims Administrator’s networks are Out-of-Network Providers, subject to Blue Cross Blue Shield Association rules governing claims filed by certain ancillary providers. For Covered Services You receive from an out-of-network Provider, the Maximum Allowed Amount for this Plan will be one of the following as determined by the Claims Administrator:

1. An amount based on the Claims Administrator’s out-of-network Provider fee schedule/rate, which the Claims Administrator has established at its’ discretion, and which the Claims Administrator reserves the right to modify from time to time, after considering one or more of the following: reimbursement amounts accepted by like/similar Providers contracted with the Claims Administrator, reimbursement amounts paid by the Centers for Medicare and Medicaid Services for the same services or supplies, and other industry cost, reimbursement and utilization data; or

2. An amount based on reimbursement or cost information from the Centers for Medicare and

Medicaid Services (“CMS”). When basing the Maximum Allowed Amount upon the level or method of reimbursement used by CMS, the Administrator will update such information, which is unadjusted for geographic locality, no less than annually; or

3. An amount based on information provided by a third-party vendor, which may reflect one or more

of the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience required for the treatment; or (3) comparable Providers’ fees and costs to deliver care; or


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4. An amount negotiated by the Claims Administrator or a third-party vendor which has been agreed

to by the Provider. This may include rates for services coordinated through case management; or

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

6. Providers who are not contracted for this product but contracted for other products with the Claims Administrator are also considered out-of-network. For this Plan, the Maximum Allowed Amount for services from these Providers will be one of the five methods shown above unless the contract between the Claims Administrator and that Provider specifies a different amount.

For Covered Services rendered outside the Claims Administrator’s Service Area by out-of-network Providers, claims may be priced using the local Blue Cross Blue Shield plan’s non-participating provider fee schedule / rate or the pricing arrangements required by applicable state or federal law. In certain situations, the Maximum Allowed Amount for out of area claims may be based on billed charges, the pricing the Plan would use if the healthcare services had been obtained within the Claims Administrator’s Service Area, or a special negotiated price. Unlike network Providers, out-of-network Providers may send you a bill and collect for the amount of the Provider’s charge that exceeds the Plan’s Maximum Allowed Amount. You are responsible for paying the difference between the Maximum Allowed Amount and the amount the Provider charges. This amount can be significant. Choosing a network Provider will likely result in lower out-of-pocket costs to you. Please call Customer Service for help in finding a network Provider or visit the Claims Administrator’s website at www.anthem.com. Customer Service is also available to assist you in determining this Plan’s Maximum Allowed Amount for a particular service from an out-of-network Provider. In order for the Claims Administrator to assist you, you will need to obtain from your Provider the specific procedure code(s) and diagnosis code(s) for the services the Provider will render. You will also need to know the Provider’s charges to calculate your out-of-pocket responsibility. Although Customer Service can assist you with this pre-service information, the final Maximum Allowed Amount for your claim will be based on the actual claim submitted by the Provider

Member Cost Share For certain Covered Services, you may be required to pay a part of the Maximum Allowed Amount as your cost share amount (deductible and/or coinsurance). Your cost share amount and out-of-pocket limits may vary depending on whether You received services from a network or out-of-network Provider. Specifically, you may be required to pay higher cost sharing amounts when using Out-of-Network Providers. Call Customer Service to learn how your cost share amounts may vary by the type of Provider you use. The Plan will not provide any reimbursement for non-covered services. You may be responsible for the total amount billed by your Provider for non-covered services, regardless of whether such services are performed by a network or out-of-network Provider. Non-Covered services include services specifically excluded from coverage by the terms of this Benefits Handbook and services received after benefits have been exhausted. Benefits may be exhausted by exceeding, for example, benefit caps or day/visit limits.



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In some instances, you may only be asked to pay the lower network cost sharing amount when You use an Out-of-Network Provider. For example, if you go to a network Hospital or Provider facility and receive Covered Services from an out-of-network Provider such as a radiologist, anesthesiologist or pathologist who is employed by or contracted with a Network Hospital or facility, you will pay the network cost share amounts for those Covered Services. However, you also may be liable for the difference between the Maximum Allowed Amount and the out-of-network Provider’s charge.

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

Services Performed During Same Session The Plan may combine the reimbursement of Covered Services when more than one service is performed during the same session. Reimbursement is limited to the Plan’s Maximum Allowed Amount. If services are performed by out-of-network Providers, then you are responsible for any amounts charged in excess of the Plan’s Maximum Allowed Amount with or without a referral or regardless if allowed as an Authorized Service. Contact the Claims Administrator for more information.

HOW TO SUBMIT A CLAIM When services are provided by a network hospital, physician or other medical provider, the claim will be filed by the provider. However, you may need to submit a Group Health Claim Form if services are received out-of-network. In this case, a form must be completed each time bills are submitted in order to receive payment of benefits. Claims must be filed by the end of the calendar year following the calendar year in which the services were received to be eligible for payment.

If You Are Hospitalized If you or a dependent goes to a hospital, present your medical plan ID card upon arrival if possible. Many hospitals may want you to complete their claim form. By signing the hospital’s form, you may be assigning benefits so that payment of benefits will be made directly to the hospital.


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Doctor’s Services If you obtain services outside of the PPO network, a Group Health Claim Form must be submitted for expenses associated with a doctor’s hospital visits; surgery, including obstetrical care; administration of anesthesia; radiotherapy services performed by a doctor; visiting nurse services; and a doctor’s home or office visits. Your doctor may complete the section provided on the back of the form, or you can itemize expenses in the appropriate section and attach the bills. A Group Health Claim Form may be obtained from your Human Resources office or the Human Resources Service Center. Claim forms may also be obtained by selecting Forms under the Benefits section on the Services and Support page of the FirstEnergy Today portal. Make sure that all applicable sections have been completed. In addition, you may be required to submit a claim form annually to update coordination of benefits information. It is fraudulent to file a claim for someone who is not eligible, submit information that you know to be false, or to omit important facts. Dismissal from employment, criminal and/or civil penalties can result from such acts. As a general rule, the bills will be satisfactory evidence of a claim if they show the name of the hospital, doctor or other medical provider; the diagnosis or nature of the illness or injury; itemized charges; an explanation of each charge and the amount of the charge. For out-of-network care, attach all bills and receipts for eligible expenses for you or your dependents to the completed Group Health Claim Form. If the information on a bill is incomplete, it will be returned to you for the missing information. For diagnostic x-ray and laboratory services, nursing and physiotherapy services and medical services and supplies, you must obtain an explanation from the doctor stating the diagnostic purpose of the service.

Coordination of Benefits Some persons have other medical coverage in addition to coverage under the Plan. When this is the case, the benefits from other plans will be taken into account, and coordinated with the benefits paid by the Plan. This may mean a reduction in benefits under this plan. The combined benefits will not be more than what the Plan would have paid if there was no other insurance coverage. This approach is called “maintenance of benefits.” The Plan will pay:

Its regular benefits in full or a reduced amount equal to: a. The benefit payable under the Plan minus; b. The benefits payable by the “other plans.”

This coordination of benefits will be based on the following rules: 1. A plan with no rules for coordination of benefits will be deemed to pay its benefits before a plan that

contains such rules. 2. A plan that covers a person as an employee will be deemed to pay its benefits before a plan that covers

the person as a dependent. 3. The plan that covers the person as a dependent of a person whose birthday comes first in a calendar

year will be primary or pay first. The plan that covers the person as a dependent of a person whose birthday comes later in that calendar year will be secondary, and pay benefits after the primary plan has


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paid. If the other plan does not have this provision regarding birthdays, then the rule set forth in the other plan will determine the order of benefits.

4. In the case of a dependent child whose parents are divorced or separated: If there is a court decree which establishes financial responsibility for the medical, dental or other health care expenses with respect to the child; the benefits of a plan covering the child as a dependent of the parent with such financial responsibility shall be determined before the benefits of any other plan which covers the child as a dependent. If there is no court decree and if the parent with custody of the child has not remarried, the benefits of a plan which covers the child as a dependent of the parent with custody will be determined before the benefits of a plan which covers the child as a dependent of the parent without custody. If the parent with custody of the child has remarried, the benefits of a plan which covers the child as a dependent of the parent with custody shall be determined before the benefits of a plan which covers that child as a dependent of the step-parent. The benefits of a plan which covers that child as a dependent of the step-parent will be determined before the benefits of a plan which covers that child as a dependent of the parent without custody.

5. If the above scenarios do not establish an order of payment, the plan under which the person has been covered for the longest will be deemed to pay its benefits first.

In order to administer this provision, the Plan can release or obtain data and can also make or recover payments. In the case of an accident, different rules may apply. See the section below on Third Party Liability and Subrogation for additional information on the rules that apply in the case of an accident.

COORDINATION WITH MEDICARE

When the FirstEnergy Health Care Plan is Primary If you are an active employee and you or your spouse has reached at least age 65, or if you or your spouse are disabled (for other than End Stage Renal Disease (ESRD) and eligible for Medicare benefits and you are still on the Company’s payroll, your primary coverage will continue to be the Company’s plan. However, when you retire you must enroll in Medicare when you become eligible. Medicare then becomes your primary coverage and the Company’s plan is secondary. You must notify the Company if you or any covered dependent becomes eligible for Medicare. If you or your spouse become Medicare eligible due to End State Renal Disease (ESRD), Medicare will be secondary payer for the ESRD coordination period. At the end of the coordination period, Medicare becomes primary payer even if you remain active and on the Company’s payroll. This Plan coordinates benefits with Medicare under the “maintenance of benefits” approach. This means that benefits paid by Medicare will be taken into account and coordinated with the benefits paid under the Plan. The combined benefits paid will not be more than what the Plan would have paid if there were no other insurance coverage. If you are retired and you or any covered dependent becomes eligible for Medicare at age 65 or you or an eligible dependent become eligible for Medicare due to disability, you must enroll in Medicare Part-B. The Plan will coordinate benefits as if you have Medicare Part-B regardless of whether or not you select it. All health claims for out-of-network care must first be submitted to Medicare for payment. You will then receive an “Explanation of Medicare Benefits” worksheet detailing what payments, if any, have been made. After receiving the Medicare worksheet, you should then complete a Group Health Claim Form for submission to the insurance company. Attach the Medicare worksheet along with a copy of the bill for


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services when filing for benefits eligible under the Plan. In most cases, if you are receiving care in-network, the hospital, doctor or other medical provider will file these claims for you. Claims submitted without Medicare worksheets will be returned to you requesting that you submit this information to the insurance company so that the expenses can be considered.

Third Party Liability and Subrogation In some cases, you or a covered dependent may incur medical expenses as the result of an injury or illness for which a third party may be liable. For example, you may incur medical expenses as the result of an injury received in an automobile accident. In these cases, the Plan has the right to recover any benefits it has paid for these medical expenses from any settlement you may receive from the third party. The Plan also has the right to act on your behalf (subrogate) in filing suit against the third party to recover the benefits it has paid for medical expenses related to the illness or injury for which the third party may be liable. If you file a claim for payment of medical expenses for which a third party may be liable, you may be asked to provide information concerning the injury or illness and who is responsible. In some cases, you may be asked to sign a release that would allow the Plan to recover any benefits it has paid from any settlement you may receive. The Plan reserves the right to withhold payment of benefits until the necessary information has been provided, or the release has been signed.

Assignment and Responsibility for Payment You authorize the claims administrator, on behalf of the Plan, to make payments directly to providers for covered services. The claims administrator also reserves the right to make payments directly to you. Payments may also be made to and notice regarding the receipt and/or adjudication of claims, an alternate recipient, or that person’s custodial parent or designated representative. Any payments made by the claims administrator will discharge the Plan’s obligation to pay for covered services. You cannot assign your right to receive payment to anyone, except as required by a QMCSO. The Plan reimburses expenses for covered medical services and supplies according to the terms of the Plan you have selected and administrator contracts. Charges that are not reimbursed by the plans are the patient’s responsibility. Generally, these would include deductibles, coinsurance, and charges for services that are not covered or greater than the Maximum Allowed Amount. Many hospitals, doctors and other medical providers ask you to sign a form accepting responsibility for all charges whether they are covered by insurance or not. To limit your liability, you may wish to indicate on the form that you will accept responsibility only for medically necessary services and supplies, up to the Maximum Allowed Amount.

Notification of Payment Generally, after a claim is processed, you will receive an Explanation of Benefits (EOB) form from the insurance company. However, in instances where benefits are assigned or a member’s liability is zero, an EOB may not be provided. The total amount of the benefit from the plan will be shown as well as the percent paid. The explanation will also show any ineligible charges and the reason they were not allowed. If you have any questions concerning the benefits paid, contact the administrator by calling the toll-free member services number listed on your identification card.


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BENEFIT CLAIMS AND APPEALS PROCEDURES The following is an outline of the procedures for the processing of a claim and summarizes the appeal of any claims determination made by the Plan Administrator or its Designee relative to the entitlement of a participant, beneficiary or other claimant to benefits offered under the Plan. The procedures defined in this document are intended to comply with the Employee Retirement Security Act of 1974 (“ERISA”) and the regulations issued by the Department of Labor related to ERISA as amended effective January 1, 2002. The Plan Administrator is FirstEnergy Service Company. The Plan includes medical benefit coverage offered to employees, retirees or their surviving spouses of FirstEnergy Corp, its subsidiaries or affiliated Companies identified as a Participating Employer below. It is not intended that the Plan Administrator will assume the responsibility for the initial claims determination or for the appeals process for any carrier or other benefit service provider to whom that responsibility has been given under agreement with FirstEnergy Service Company and/or its subsidiaries or affiliates. Any carrier or benefit service provider who has agreed to act as a fiduciary for the purpose of initial claims determination or for the appeals process shall be hereinafter referred to as “Designee”. For the 2018 “plan year”, the carrier or benefit service provider that you elected during open enrollment has agreed to be the fiduciary, or “Designee” for claims and appeals processing.

Claims Process A Claim as referred to in this document is a request for a Plan benefit. Claims for benefits must be in writing, signed by the participant, beneficiary, other claimant or their authorized representative, and submitted on the appropriate form and in a manner acceptable to the Plan Administrator or its Designee. A claim for a benefit includes any urgent, pre-service or post-service claim. In the case of a claim involving urgent care, the Designee shall notify the Claimant of the Plan’s benefit determination as soon as possible, taking into account the medical exigencies, but not later than 72 hours after the receipt of the claim by the Plan, unless the claimant fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the Plan. In such case the Designee shall notify the Claimant as soon as possible, but not later than 24 hours after receipt of the claim by the Plan, of the specific information necessary to complete the claim. The Claimant shall have not less than 48 hours to provide the specified information. The Designee shall then notify the Claimant of the Plan’s benefit determination as soon as possible, but in no case less than 48 hours after the Plan’s receipt of the specified information or the end of the period afforded the claimant to provide the specified additional information. If the Plan has approved an ongoing course of treatment, any reduction or termination of such course of treatment before its scheduled end shall constitute an adverse benefit determination and the Designee must notify the Claimant of this determination. This notification must be sufficiently in advance of the reduction or termination so as to allow the Claimant to appeal and obtain a determination on review of that adverse benefit determination before the benefit is reduced or terminated. Any request by a claimant to extend the course of treatment that involves urgent care shall be decided as soon as possible, and the claimant shall be notified of the determination within 24 hours after the receipt of the claim. In the case of a pre-service claim the Designee shall notify the claimant of the benefit determination no later than 15 days after the receipt of the claim. This period may be extended one time by up to 15 days provided the extension is necessary due to matters beyond the control of the Plan and the claimant is notified prior to the expiration of the initial 15 day period, of the circumstances requiring the extension and the date the Plan expects to render a determination.


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In the case of a post-service claim, the Designee will notify the claimant of the Plan’s adverse determination of entitlement to benefits not later than 30 days after the receipt of the claim. This period may be extended one time by up to 15 days provided the extension is necessary due to matters beyond the control of the Plan and the claimant is notified prior to the expiration of the initial 30-day period, of the circumstances requiring the extension and the date the Plan expects to render a determination. If the Designee denies any part, or all, of the initial claim for benefits, the claimant will be notified in writing, stating the reason for the denial and the Plan provisions on which the denial is based. The claimant shall be entitled to receive, upon written request, reasonable access to and copies of all documents, records and other information relevant to the claim for benefits. The denial will provide a description of any additional information or material necessary for the claimant to perfect the claim and an explanation as to why the additional information or material is required. The denial will further provide an explanation of the claims appeal procedure and the time limits for filing an appeal. Such notice of denial or any other notice as referred to in this procedure shall be deemed duly given when addressed to the claimant and mailed by first class mail to the address last appearing in the records of the Plan Administrator or Designee. The claimant shall have 180 days from the date of the initial benefit determination to file an appeal. The appeal must be in writing, unless the claim involves urgent care or the Designee otherwise permits verbal appeals. The claimant will have the opportunity to submit written comments, documents or other information in support of the claim as part of the appeal. The appeal must be submitted to the Designee that made the initial claims determination, at the address, fax or phone number provided on the initial claim denial. If the Designee permits a verbal appeal, or the appeal involves urgent care, all necessary information shall be transmitted to the Designee by telephone, facsimile, or other available similarly expeditious method.

Appeals Process The Designee will review and make its decision on the appeal. The claimant shall be provided two levels of appeal. The claimant shall have 60 days to file a second appeal once they have been notified of the decision on the first level of appeal. This second level of appeal shall be sent to the same address as the first appeal. The claimant can bypass this voluntary second level appeal and request an External review at this time. For urgent care claims, the Designee shall notify the claimant of the Plan’s determination on review as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the claimant’s request for review. A second level review is available at this time, however, the claimant may bypass the voluntary second level review and request an External review at this time. For pre-service claims, the Designee shall provide the claimant notice of the Plan’s determination on review, not later than 30 days after receipt by the Plan of the claimant’s request for review of the adverse determination or the Plan’s first determination on review. A second level review is available, however, the claimant may bypass the voluntary second level appeal and request an External review. The Designee shall provide the claimant notice of the Plan’s determination on the voluntary second level review not later than 30 days. For post service claims, the Designee shall provide the claimant notice of the Plan’s determination on review, not later than 60 days after receipt by the Plan of the claimant’s request for review of the adverse determination. A second level review is available, however, the claimant may bypass the voluntary second level appeal and request an External review. The Designee shall provide the claimant notice of the Plan’s determination on the voluntary second level review not later than 60 days.


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The Independent Review Organization (IRO) will provide claimant notice of determination on the External review, conducted by the IRO for an urgent request or after completion of the mandatory first level review not later than 45 days from receipt of request by the IRO. In making its decision, the Designee will have full power and authority to interpret the Plan, to resolve ambiguities, inconsistencies and omissions, to determine any question of fact, to determine the right to benefits of, and the amount of benefits, if any, payable to the claimant in accordance with the provisions of the Plan. The Designee will not defer to the original determination but will independently review the initial claim for benefits and consider all comments, documents and other information submitted as part of the appeal in making its decision. In addition, neither the person who made the adverse determination nor that person’s subordinate will participate in the decision on the appeal. If an appeal is based on medical judgment, the Designee shall consult with a health care professional with the appropriate training and experience in making its decision. The health care professional consulted by the Designee will not be the same person consulted in the adverse determination or that person’s subordinate. If the Designee’s decision is to uphold the denial of benefits, the notification will include the reason for the denial and the Plan provisions on which the denial is based. The claimant shall be entitled to receive, upon written request, reasonable access to and copies of all documents, records and other information on which the decision was based. The decision will further provide a notice of the participant’s right to appeal the decision of the Designee or IRO in accordance with ERISA and the time limits for filing an appeal. The claimant must exhaust the above appeals process prior to any action at law, in equity, pursuant to arbitration or otherwise. The participant shall have 180 days from the date of the decision of the Designee or IRO to file an appeal action under ERISA. No legal action may be commenced against the Plan, the Plan Administrator, the Designee or IRO more than 180 days after the decision has been made with respect to all or any portion of the claim for benefits. The address for the claim to file an appeal is: Anthem Blue Cross Blue Shield Clinical Appeals: P.O. Box 105568 Atlanta, GA 30348

Legal Claims Any civil suit brought against the Plan, its Administrator, Sponsor or any other Plan fiduciary may only be submitted and filed in the United States District Court for the Northern District of Ohio.

CLAIMS AND APPEALS OTHER THAN FOR BENEFITS A separate claims procedure shall apply to claims regarding eligibility or participation by any eligible employee or eligible retired employee, eligibility for a dependent to be entitled to coverage or benefits, and to claims other than claims for group health benefits. To the extent that an applicable collective bargaining agreement provides for different claims procedures than the claims procedures set forth herein, then such other claims procedures shall apply to claims made by individuals who are subject to such collective bargaining agreement. Any participant who wishes to file a claim for any benefit relating to the terms of eligibility or participation under the Plan, including but not limited to eligibility to participate in any benefit program or coverage option, the dependent status of an individual, eligibility to make a mid-year change in a coverage election,


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eligibility to pay premiums on a pre-tax or after-tax basis, the amount of any premium, or for benefits other than group health benefits, shall file such claim with the Administrator. The address for filing a claim with the Administrator is: FirstEnergy Health Care Plan Attention: Plan Administrator 76 South Main Street, 7th floor Akron, Ohio 44308

Initial Claim Decision for Claims Relating to Eligibility and Participation The Administrator shall process each properly filed claim within a reasonable time but not later than 90 days after its receipt of an application for benefits. This period may be extended by an additional 90 days if the Administrator provides the claimant with written notice of the extension within the initial 90-day period. The extension notice shall explain the reason for the extension and the date by which the Administrator expects a decision will be made. If the extension is necessary because additional information is needed to decide the claim, the extension notice shall describe the required information. The claimant should provide the required information as soon as possible. The Administrator shall notify the claimant in writing, delivered in person or mailed by first-class mail to his last known address, if any part of a claim has been denied. The notice of a denial of any claim shall include: (i) the specific reasons for the denial; (ii) a reference to specific provisions of the plan document upon which the denial is based; (iii) a description of any internal rule, guidelines, protocol or similar criterion relied on in making the denial (or a statement that such internal criterion will be provided free of charge upon request); (iv) a description of any additional material or information deemed necessary by the Administrator for the claimant to perfect his claim and an explanation of why such material or information is necessary; and (v) an explanation of the claims review procedure under the plan. If the notice described above is not furnished and if the claim has not been granted within the time specified above, the claim shall be deemed denied and shall be subject to review as set forth below.

Appeals of Denied Claims Relating to Eligibility and Participation If a claim is denied, in whole or in part, the claimant may request that the Appeals Committee review his or her claim. A claimant shall have 60 days in which to request a review. Such request shall be in writing and delivered to the Appeals Committee. The address for the Appeals Committee is: FirstEnergy Corp. Employee Benefit Claims and Appeals Committee 76 South Main Street, 7th floor Akron, Ohio 44308 If no such review is requested, the decision of the Administrator shall be considered final and binding. A request for review must specify the claimant’s reason(s) for requesting that the denial be reversed. The claimant may submit additional written comments, documents, records, and other information relating to and in support of his claim; all information submitted shall be reviewed whether or not it was available for the initial review. A claimant may request reasonable access to, and copies of, all documents, records, and other information relevant to his claim for benefits. If a review is requested, a full and fair review of the decision will be made by a person different than, and who is not a subordinate of, the original decision maker.

The Appeals Committee shall render its final decision within a reasonable period of time but not later than 60 days from its receipt of a request for review. This period may be extended up to an additional 60 days, if the Appeals Committee determines that special circumstances exist (such as the need for a hearing) which


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require an extension of time for processing the review. The Appeals Committee shall provide the claimant with written notice of the extension within the initial 60 day period. The extension notice will explain the reason for the extension and the date by which the Appeals Committee expects a decision will be made. If the extension is necessary because additional information is needed, the extension notice will describe the required information. The claimant should provide the required information as soon as possible.

If after review the claim continues to be denied, the Appeals Committee shall provide the claimant with a notice of the denial of his appeal which shall contain the following information: (i) the specific reasons for the denial of the appeal; (ii) a reference to the specific provisions of the plan document on which the denial was based; (iii) a statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to his claim for benefits; (iv) a statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making the denial (or a statement that such information would be provided free of charge upon request); and (v) a statement describing his right to bring a civil suit under Federal law no later than 180 days after receipt of the denial and a statement concerning any other voluntary alternative dispute resolution options that may be available.

Legal Claims Any civil suit brought against the Plan, its Administrator, Sponsor or any other Plan fiduciary may only be submitted and filed in the United States District Court for the Northern District of Ohio.

BENEFITS UPON TERMINATION

Termination of Coverage Termination of coverage for you and your eligible dependents will, in most cases, terminate at the end of the month in which you leave the Company; if you cease to be an eligible employee; or if the Plan is discontinued. Coverage will also terminate immediately if the required employee contribution, if applicable, has not been made. A dependent’s coverage will terminate at the end of the month in which he or she is no longer an eligible dependent.

Your Rights to Continued Health Care Coverage The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 is an act of Congress that protects you and your dependents from loss of group health care coverage if certain events occur that would otherwise result in your loss of coverage. When your coverage as an active employee ends you can elect continued coverage — at your own expense and without evidence of good health — which is identical to the coverage provided for all other employees. Coverage may be continued for a period of 18, 29, or 36 months for the following COBRA qualified reasons: ♦ Loss of coverage due to termination of employment. If your employment is terminated due to any

reason other than gross misconduct, you and your covered dependents may continue health care coverage for up to 18 months.


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♦ Eligibility for continued coverage because of disability. If you or your dependent are Social Security disabled at the time you qualify for COBRA, coverage may be extended from 18 months to 29 months. You must be eligible for Social Security disability benefits and notify the Company of your eligibility for Social Security disability benefits before your first 18 months of COBRA expire.

♦ Termination of coverage due to a divorce or death. If you should die, or become divorced, your covered

dependents may continue group health care coverage for up to 36 months. If you are already covered by COBRA under the 18-month provision, and any of the preceding events occur, your dependents can extend coverage to a maximum of 36 months from the first date of eligibility for COBRA coverage. If a former Allegheny Energy employee hired after January 1, 1993 dies prior to retirement and his/her spouse is covered at the time, they may continue to be covered by this Plan by paying the appropriate premium until they become covered under the group medical plan through another employer, reach age 65 or commence survivor pension benefits. Dependent children may continue to be covered by this Plan until they reach the normal dependent age.

♦ Termination of coverage due to a loss of eligibility. You or your covered dependents may continue group health care coverage for up to 36 months after you are no longer eligible or your dependents no longer qualify as covered dependents. Note: If you are already covered by the 18-month provision, your dependents can extend coverage to a maximum of 36 months from the first date of eligibility for COBRA coverage.

How to Continue Coverage If your employment ends for any reason other than gross misconduct, you will receive notification from FirstEnergy’s COBRA administrator with a detailed explanation of your COBRA rights and all necessary application forms. Under the COBRA law, the employee or family member has the responsibility to inform the local Human Resources representative or the Human Resources Service Center of a divorce, legal separation, or change in eligibility for a dependent child covered under the Plan. Notice must be received in writing within 60 days of the later of (i) date the qualifying event occurs, or (ii) the date the qualified beneficiary loses coverage as a result of the event. The participant will have 60 days from the date of the qualifying event to elect continuation of coverage. If notice is not received within 60 days of the qualifying event, the right to continue coverage will be lost. When notice is received, you and your dependents will be notified about your rights to continue coverage under COBRA. If you or a covered dependent decides to continue coverage, the election must be completed within 60 days of the date notification was received.

The Cost of Continued Coverage You are responsible for paying the cost or premium for continued group health care coverage. The monthly premium for continued coverage will be included in the notice sent to you or your dependents. Once you have elected to continue group health care coverage, the first premium must be received by FirstEnergy’s COBRA administrator within 45 days after continued coverage is elected. Premiums for continued coverage are due on the first day of each month. If the required premium is not paid within 30 days from the first of the month, coverage will be terminated.

When Continued Coverage Ends Your group health care coverage will continue until the earliest of the following: ♦ The required monthly premiums are not paid;


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♦ The person becomes covered by another group health plan (unless a pre-existing condition clause used in the other plan prevents coverage);

♦ The person becomes eligible for Medicare; ♦ The date the Company terminates all of its group health care plans;

After a period of 18, 29, or 36 months of continued coverage depending upon the circumstances of the termination of coverage. When continued coverage is no longer available, you or your dependents may convert coverage to an individual health insurance policy.

Conversion to an Individual Health Insurance Policy If coverage for you or your dependents ends for any reason under the Plan, you may convert your coverage to an individual health insurance policy, if offered by the administrator, on a direct payment basis. Application for this conversion policy must be made within 31 days of the date coverage terminates. The conversion option is also available at the end of the continuation period as described in the section entitled “Your Rights to Continued Health Care Coverage.” Application for an individual health insurance policy may be made within 180 days before the end of the continuation period. Instructions on how to apply for conversion may be obtained from the Human Resources Office at your location or the Human Resources Service Center.

HIPAA PRIVACY NOTICE The Plan will only disclose Protected Health Information (PHI) to the Employer in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Plan agrees not to use or further disclose PHI other than as permitted in its privacy notice or as required by law. The Plan will train any employees who have access to PHI regarding the requirements of HIPAA. The Plan ensures that any of its business agents that receive PHI from the Plan agree to the same restrictions and conditions. PHI will not be used or disclosed for employment-related actions or in connection with any other benefit or employee benefit plan. Access to and use of PHI by Human Resources personnel shall be restricted to plan administration functions performed for the Plan. Such access or use shall be permitted only to the extent necessary to perform the duties of the Plan.

Seeking assistance from Human Resources The Plan will attempt to limit PHI received from participants or beneficiaries by encouraging participants and beneficiaries to directly contact the provider who administers benefits payable by the applicable health and welfare plan. However, in the event that the Company receives PHI, the following procedures will be in effect to protect the privacy of that information. The Company will designate specific Human Resources representatives to have access to PHI at each Company location. To the extent possible, only the designated Human Resources representative and members of the Benefits section of the Human Resources Department will have access to PHI. Under HIPAA regulations, designated Human Resources representatives or members of the Benefits section of Human Resources will not be permitted to disclose PHI to a health care provider unless authorized in writing by the participant/beneficiary or their authorized personal representative.


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LEGISLATIVE CHANGES The FirstEnergy Health Care Plan and the FirstEnergy Prescription Drug Plan are complaint with the Patient Protection and Affordable Care Act (the “Affordable Care Act”). Questions regarding which changes apply to these plans should be directed to the plan administrator: FirstEnergy Health Care & Prescription Drug Plans, 76 South Main Street, Akron, OH 44308, Attn: Plan 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 table summarizing which protections do and do not apply to grandfathered health plans.

Mental Health Parity and Addiction Equity Act The Federal Mental Health Parity and Addiction Equity Act (MHPA) signed into law and effective January 1, 2010 amends the previous Mental Health Parity Act. The MHPA requires “parity” between the financial requirements and treatment limitations applied to medical and/or surgical benefits and mental health and substance abuse disorder benefits. The Plan will comply with MHPA. The medical plan comparison chart in this guide reflects the elimination of the 30-day inpatient treatment days and 30-visit outpatient limitations. Out-of-network mental health or substance abuse treatment charges will no longer be excluded from the out-of-pocket maximum limit. Additionally, there will no longer be a separate maximum lifetime benefit for chemical dependency treatment.

OTHER FACTS AND INFORMATION

Certificate of Credible Coverage Plan members may request a certificate of credible coverage under HIPAA by calling the FirstEnergy Human Resources Service Center at 1-800-543-4654 during regular business hours.

Benefit Rights This summary describes the current level of benefits and contributions required for active employees, retirees, and eligible dependents. The decision to offer medical benefits and the levels of coverage are based on management decision or with respect to bargaining unit employees, upon the agreements reached between the Company and the unions. Retirement health care benefits are not vested. Medical benefits and the contributions required for coverage including retiree health care benefits and contributions may be amended or terminated at any time by the Chief Executive Officer of FirstEnergy Corp. or his appointed designee.

Source of Benefits Medical benefits are provided under an arrangement described in the Group Health Care Policies whereby the benefits are to be afforded directly by the Company. The complete terms of the Plan are set forth in this summary plan description and as administered under the terms of the Administrative Services Agreement by a third party Administrator. The extent of the coverage for each individual is governed at all times by the terms of the Group Policy. The administrator determines the benefits for which an individual qualifies under the Plan, whether provided directly by the


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Company or by the insurance company. All payments are based upon that determination.

VEBA The Company has established trusts to pre-fund a portion of its post-retirement medical liability for current and some future retirees. These trusts are called a Voluntary Employee Benefit Associations (VEBA’s) and will be operated to receive favorable tax treatment under IRS Section 501(C)(9). The VEBA’s are as follows:

• Ohio Edison Company Postretirement Health Benefits Trust for Management and Non-represented Employees.

• Ohio Edison Company Postretirement Health Benefits Trust for Represented Employees. • Trust Agreement for GPU Companies Health Care Plan for Non-bargaining Retirees. • Trust Agreement for GPU Companies Health Care Plan for Employees Represented by IBEW

System U-3. • Trust Agreement for GPU Companies Health Care Plan for Employees Represented by IBEW

Local 777. • Trust Agreement for GPU Companies Health Care Plan for Employees Represented by IBEW

Local 459 and UWUA Local 180. • Trust Agreement for GPU Companies Health Care Plan for Non-bargaining Employees. • Trust Agreement for Allegheny Power System Benefit Fund– Medical (APEF1707502,

APEF1707432, APEF1707422, and APEF1710422) for all non-bargaining and pre-1/1/1993 retirees except for Local 102.

• Trust Agreement for Monongahela Power Company – Medical (APRF1745692) for all pre-1/1/1993 retirees for Local 2357 and 162.

• Trust Agreement for Potomac Edison Company – Medical (APRF1745702) for pre-1/1/1993 retirees of Local 307, 771 and 331.

• Trust Agreement for West Penn Power Company – Medical (APRF1745742) for all pre-1/1/1993 retirees of Local 102.

Trust assets are used to pay health benefits for active and retired employees, and the administrative costs of the trust and Plan. The amount of funding, timing of contributions, administration, and funding policy will be determined by the Plan Sponsor. The creation, administration, and funding of these trusts does not preclude the Plan Sponsor from amending, modifying, or terminating the health care benefits at any time. Post-retirement medical benefits are not vested.

Participant’s Rights As a participant in the Plan you are entitled to: ♦ Examine, without charge, at the Plan Administrator’s office and plant or regional human resources

offices, a copy of the Plan, the latest annual report and the Plan description; ♦ Obtain copies of Plan documents and other Plan information upon written request to the Plan

Administrator. The Administrator may make a reasonable charge for the copies; ♦ Receive a summary of the Plan’s annual financial report; and ♦ Expect that the people who operate your Plan, called “fiduciaries” of the Plan, will do so prudently and

in the interest of you and other Plan participants and beneficiaries.


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No one — your employer, your union, or any other person — may fire you or otherwise discriminate against you in any way to prevent you from obtaining a Plan benefit or exercising your rights under the Employee Retirement Income Security Act of 1974 (ERISA). Under ERISA, there are steps you can take to enforce your rights. For instance, if you request materials and do not receive them for 30 days, you may file suit in federal court (Northern District of Ohio). If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal court. If it should happen that Plan fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. If you are successful, the court may order the person you have sued to pay court costs and legal fees; if you lose, the court may order you to pay these costs and fees. If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, you should contact the nearest area office of the Employee Benefits Administration listed in your telephone directory, or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration; U.S. Department of Labor, 200 Constitution Avenue NW, Washington, D.C. 20210.

Plan is Not an Employment Contract The Plan shall not be deemed to constitute a contract between the participating employer and any employee nor shall anything herein contained be deemed to give any employee any right to be retained in the employ of the participating employer or to interfere with the right of the participating employer to discharge any employee at any time and to treat the employee without regard to the effect which such treatment might have upon the employee as a participant in the Plan.

Right to Amend Plan The Plan may be amended or terminated by the Chief Executive Officer of FirstEnergy Corp. or his appointed designee at any time or for employees represented by a labor union in accordance with the applicable collective bargaining agreements.

Administration The Plan Administrator has the authority to control and manage the operation and administration of the Plan with benefits provided in accordance with the provisions of the group policy issued by the insurance company. Inquiries should be made to the Plan Administrator: FirstEnergy Service Company 76 South Main Street, 7th floor Akron, OH 44308 1-800-543-4654

Plan Sponsor FirstEnergy Corp. is the Plan Sponsor for the Plan General inquiries about the Plan may also be directed to the administrators that have contracted with FirstEnergy Service Company to process claims. Any questions about benefit coverage for a medical


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service or supply, or the processing of a claim should be directed to Member Services for the administrator you have elected for coverage at the address or telephone number below.

Anthem Blue Cross/Blue Shield 220 Virginia Avenue

Indianapolis, IN 46204-3632 1-866-236-4365

www.anthem.com

Type of Plan The Plan is a welfare benefit plan.

Plan Number 501

Agent for Service of Legal Process CT Corporation System 400 Easton Commons Way Suite 125 Columbus, OH 43219

Fiscal Year The last day of the Plan’s fiscal year is December 31.

PARTICIPATING EMPLOYERS AND IDENTIFICATION NUMBERS FirstEnergy Service Company Ohio Edison Company EIN 34-1968288 EIN 34-0437786 Pennsylvania Power Company The Cleveland Electric Illuminating Company EIN 25-0718810 EIN 34-0150020 The Toledo Edison Company Jersey Central Power & Light Company EIN 34-4375005 EIN 21-0485010 Metropolitan Edison Company Pennsylvania Electric Company EIN 23-0870160 EIN 25-0718085 FirstEnergy Nuclear Operating Company FirstEnergy Solutions Corp. EIN 34-1881483 EIN 31-1560186 American Transmission Systems, Incorporated FirstEnergy Generation, LLC EIN 34-1882848 EIN 34-1940561



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Potomac Edison Company West Penn Power Company EIN 13-5323955 EIN 13-5480882 Monongahela Power Company EIN 13--5229392 Additions or deletions to the list of Participating Employers may be made at any time at the sole discretion of the Program Sponsor. An up-to-date listing of Participating Employers may be obtained from the Plan Administrator.

PARTICIPATING UNIONS Additions or deletions to the list of Participating Unions may be made at any time at the sole discretion of the Program Administrator. An up-to-date listing of Participating Unions may be obtained from the Plan Administrator.

Participating Unions in accordance with the labor agreement between The Toledo Edison Company, FirstEnergy Nuclear Operating Company and FirstEnergy Generation, LLC and: International Brotherhood of Electrical Workers, A.F.L.-C.I.O. Local Union No. 245 Participating Unions in accordance with the labor agreement between FirstEnergy Generation, LLC and: International Brotherhood of Electrical Workers A.F.L.-C.I.O. Local Union No. 272* Utility Workers Union of America, A.F.L.-C.I.O. Local Union Nos. 350/351 Utility Workers Union of America, A.F.L.-C.I.O. Local Union No. 457 Participating Unions in accordance with the labor agreement between Metropolitan Edison Company and: International Brotherhood of Electrical Workers A.F.L.-C.I.O. Local Union No. 777* International Brotherhood of Electrical Workers A.F.L.-C.I.O. Local Union No. 777S – Reading Call Center* Participating Unions in accordance with the labor agreement between Ohio Edison Company and: International Brotherhood of Electrical Workers A.F.L.-C.I.O. Local Union No. 1194


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Utility Workers Union of America, A.F.L.-C.I.O. Local Union Nos. 118/126* Participating Unions in accordance with the labor agreement between The Toledo Edison Company and FirstEnergy Nuclear Operating Company and: International Brotherhood of Electrical Workers A.F.L.-C.I.O. Local Union No. 1413* Participating Unions in accordance with the labor agreement between Jersey Central Power and Light Company and: International Brotherhood of Electrical Workers A.F.L.-C.I.O. System Council Local 1289 Participating Unions in accordance with the labor agreement between The Toledo Edison Company, FirstEnergy Service Company, FirstEnergy Nuclear Operating Company, FirstEnergy Generation, LLC and: Office & Professional Employees International Union, A.F.L.-C.I.O. Local Union No. 19 Participating Unions in accordance with the labor agreement between Pennsylvania Power Company and: Utility Workers Union of America, A.F.L.-C.I.O. Local Union No. 140* Participating Unions in accordance with the labor agreement between Pennsylvania Electric Company and: Utility Workers Union of America, A.F.L.-C.I.O. Local Union No. 180* International Brotherhood of Electrical Workers, A.F.L.-C.I.O. Local Union No. 459 Participating Unions in accordance with the labor agreement between The Cleveland Electric Il luminating Company, FirstEnergy Nuclear Operating Company and FirstEnergy Generation, LLC and: Utility Workers Union of America, A.F.L.-C.I.O. Local Union No. 270 * Participating Unions in accordance with the labor agreements between The FirstEnergy Nuclear Operating Company and:


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International Brotherhood of Electrical Workers A.F.L.-C.I.O. Local Union No. 29* International Brotherhood of Electrical Workers A.F.L.-C.I.O. Local Union No. 29MP* Utility Workers Union of America, A.F.L.-C.I.O. Local Union No. 270 (Perry Techs)

Participating Unions in accordance with the labor agreements between West Penn Power, Potomac Edison, FirstEnergy Generation, LLC and FirstEnergy Service Company, and: Utility Workers Union of America, A.F.L.-C.I.O. Local Union No. 102* Participating Unions in accordance with the labor agreement between Monongahela Power Company and: International Brotherhood of Electrical Workers, A.F.L.-C.I.O. Local Union No. 2357 Participating Unions in accordance with the labor agreement between Allegheny Energy Service Corporation on behalf of Allegheny Energy Supply, LLC and the Potomac Edison Company and West Penn Power Company doing business as Allegheny Energy: International Brotherhood of Electrical Workers, A.F.L.-C.I.O. Local Union No. 50 Participating Unions in accordance with the labor agreements between Monongahela Power Company and FirstEnergy Generation, LLC and: Utility Workers Union of America, A.F.L.-C.I.O. Local Union No. 304 * Member of these unions are eligible for the Consumer HDHP only.

Documents

Employee Compensation & Benefits HandbookEmployee Compensation & Benefits Handbook MP 01 2019 Page 5 of 60 Same-sex spouses can be covered under the plan as long as valid marriage