WIXLIB

CHRISTIAN BROTHERS EMPLOYEE BENEFIT TRUSTMEDICAL AND PRESCRIPTION DRUGSUMMARY PLAN DOCUMENT

TABLE OF CONTENTSINTRODUCTION ----------- 11.2.3.A.B.C.D.E.PLAN INFORMATION --------------------------------------- 1Plan Benefits ---------------------------------------------- 2Plan Interpretation -------------------------------------- 2Conformity with State Mandates ------------------- 2Conformity with Federal Mandates ---------------- 2HIPAA ----- 2A.B.C.D.E.F.G.H.I.J.SUMMARY OF MEDICAL & PRESCRIPTION DRUG BENEFITS - 3Comprehensive Medical & Prescription Drug Benefits Payable ------------------------------ 3Medical Preferred Provider Organization (PPO) -------------------------------------------------- 3Prescription Drug Pharmacy Network ------------- 3Medical Emergency ------------------------------------- 3Uncontrollable Medical Providers ------------------ 4Medical and Prescription Drug Deductible(s) ---- 4Medical and Prescription Drug Copayment & Coinsurance Amounts ----------------------- 4Medical andPrescription Drug Out-of-Pocket Expense Maximum(s) ------------------------ 4Brand Name versus Generic --------------------- 5Generic Drug Substitution ---------------------------- 5ELIGIBILITY -- 5Who is Eligible -------------------------------------------- 5When You are Eligible for Coverage ---------------- 6When Your Dependents are Eligible for Coverage ----------------------------------------------- 7Newborns -------------------------------------------------- 7How You Enroll for Coverage ------------------------- 7When You Become Enrolled for Coverage -------- 71)Noncontributory Coverage ----------------------- 72)Contributory Coverage ----------------------------- 73)Special Enrollment Provisions -------------------- 7a)Loss of Other Coverage ------------------------ 7b)Newly Acquired ---------------------------- 8c)Court-Ordered ------------------------------- 8d)Loss of Medicaid or CHIP Coverage --------- 8e)Eligibility for Employment Assistance Under Medicaid or CHIP ----------------------- 8G.Change in Family Status ------------------------------- 9H.When Your Coverage Terminates ------------------- 9A.B.C.D.E.F.Effective 1-1-2021iiMedical/RX/Standard

I.J.4.1)2)3)4)Continuation ------------------------------------------- 9Employee and Dependent Continuation Privilege -------------------------------------------- 9Retiree Continuation Privilege ------------------- 9Federal Family and Medical Leave Act (FMLA) ---------------------------------------- 10Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) Continuation ---------------------------- 10Rescission ------------------------------------------------ 10COMPREHENSIVE MEDICAL COVERAGE ------------ 11Lifetime Benefit Maximum ------------------------- 11Medical Benefits ----------------------------------- 11Covered Charges --------------------------------------- 11Covered Charges for an Assistant during Surgical Procedures ------------------------------ 12Covered Charges for Multiple Surgical Procedures -------------------------------------------- 13Other Covered Charges ------------------------------ 13Organ and Tissue Transplant Benefits ----------- 161)Covered Transplant ------------------------------- 162)Benefits Payable; Within the Transplant Network ----------------------------------------- 173)Benefits Payable; Outside the Transplant Network ---------------------------------------- 174)Limitations: Applicable Within and Outside the Transplant Network ----------------- 18H.Transportation Benefits ----------------------------- 18I.Compliance with Federal Law ---------------------- 191)Newborns' and Mothers' Health Protection Act of 1996 --------------------------------- 192)Women's Health and Cancer Rights Act of 1998 -------------------------------------------- 19J.Limitations of Medical Benefits -------------------- 19K.Utilization Management Requirements --------- 221)Hospitalization ------------------------------------- 222)Outpatient Diagnostic Imaging ---------------- 243)Outpatient --------------------------------------- 24L.Notice of Utilization Review ------------------------ 251)Prospective Review ------------------------------- 262)Urgent Prospective Review --------------------- 263)Concurrent Review -------------------------------- 264)Retrospective Review ---------------------------- 275)Request for Reconsideration ------------------- 276)Expedited Appeal Review and Voluntary Appeal Review --------------------------------- 277)Standard Appeal Review and Voluntary Appeal Review ---------------------------------- 28M. Medical Claim Procedures -------------------------- 281)Claim Forms ----------------------------------------- 282)Payment and Denial ------------------------------ 283)Independent Medical Examinations ---------- 284)Release of Medical Information --------------- 29A.B.C.D.E.F.G.Effective 1-1-2021iiiMedical/RX/Standard

3)4)5)6)7)8)9)Form and Content of Notice of Adverse Benefit Determinations ---------------------- 29Right of Recovery -------------------------------------- 29Assignment of Benefits -------------------------- 30Applicability ----------------------------------------- 30Transfer of Rights ---------------------------------- 30Medical Appeal Procedures ------------------------ 30Internal Appeal ------------------------------------- 30External Appeal ------------------------------------ 31Right to External Appeal ------------------------- 32Notice of Right to External Appeal ------------ 32Independent Review Organization ----------- 32Notice of External Review Determination -- 33Assignment ------------------------------------------ 33Coordination with Other Benefits – Medical --- 33When Coordination Applies -------------------- 33Benefits Payable under Coordination -------- 34Order of Benefit Determination --------------- 34Coordination with HMOs ------------------------ 35Coordination with Excess Only or Secondary Only Plans --------------------------------- 35Integration With Medicare --------------------- 35Exchange of Information ------------------------ 35Facility of Payment -------------------------------- 36Reimbursement/Subrogation ------------------ 36PRESCRIPTION DRUG COVERAGE -------------------- 36Description of Benefits ------------------------------- 361)Retail Network Pharmacy ----------------------- 362)Mail Order Pharmacy ----------------------------- 36Your -------------------------------------------------- 37Covered Charges --------------------------------------- 37Payment of Prescription Drug Benefits ---------- 37Prescription Drug Management ------------------- 37Limitations for Prescription Drug Coverage ---- 40How to Order From the Mail Order Pharmacy -------------------------------------------------- 411)The Written Prescription ------------------------ 412)Patient Profile Order Form ---------------------- 413)Copayment and/or Deductible ---------------- 414)Refills or Follow-up ---------------------------- 415)Special Situations ---------------------------------- 426)Questions -------------------------------------------- 42Prescription Appeal Procedures ------------------- 42Effective 1-1-2021ivMedical/RX/Standard

1)2)3)4)5)6)Coverage review description ------------------- 42How to request an Initial Coverage Review -------------------------------------------------- 42How to request a Level 1 Appeal -------------- 42How to request a Level 2 Appeal -------------- 43External Review ------------------------------------ 43Urgent External Review -------------------------- 44I.Coordination with Other Benefits – Prescription Drugs -------------------------------------- 441)Reimbursement/Subrogation ------------------ 44Effective 1-1-2021vMedical/RX/Standard

FAFederal Family and Medical Leave Act . 10FMLA. 10Formulary . 5, 37Advanced Practice Registered Nurse . 12, 13Ambulatory Surgery Center . 11, 12BGBirthing Center . 11, 12, 23Brand Name Prescription Drug . 5Generally Accepted . 11, 16Generic Prescription Drug . 5CHCertified Nurse Anesthetist . 13Certified Nurse Midwife. 12, 13Claim Determination Period . 34Clinical Coverage Review Request . 42Coinsurance . 3, 4, 5, 18, 19, 37Concurrent Review. 26, 27Copayment . 3, 4, 5, 18, 19, 36, 37, 41, 42Cosmetic . 20, 40Cost Containment Administrator. 2, 16, 18, 19, 22, 23, 24, 25, 26, 27, 28Covered Charges . 3, 4, 5, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, 25, 35, 36, 37,40Covered Person . 3, 4, 5, 11, 13, 15, 16, 17, 22, 26, 28, 29, 30, 32, 33, 34, 35, 36, 37, 40,41, 42, 44Covered Transplant . 16, 17, 18Custodial Care . 21, 23Habilitation. 13Health Care Extender . 12, 13, 14Home Health Aide . 15Home Health Care Agency . 15, 40Home Health Care Plan . 15Hospice Care Program . 16Hospice Care Services. 15, 16Hospital . 3, 4, 7, 11, 12, 13, 14, 15, 19, 22, 23, 26, 27, 28, 33, 40Hospital Admission Review. 22, 23, 24, 26Hospital Inpatient Confinement . 12, 14, 15, 22, 23, 24IImmediate Family . 22, 41Initial Clinical Review . 25Initial Clinical Reviewer . 25Inpatient Alcohol or Drug Abuse Treatment Facility . 23DDeductible . 3, 4, 5, 16, 17, 18, 19, 36, 37, 41Dental Services . 13, 14, 20Dependent. 3, 5, 6, 7, 8, 9, 10, 14, 22, 23, 24, 29, 34, 35, 41Direction and Supervision . 14

Christian Brothers Services . 1205 Windham Parkway Romeoville, IL 60446-1679 . Telephone: 800-807-0100 . EIN: 36-3884439 . Plan Year: Christian Brothers Employee Benefit Trust is a Calendar Year Plan. Your Plan Year may be different. See Summary of Benefits and Coverage for Your Plan Year specifics. Agent for Service or Legal Process: Christian .