This Plan will coordinate benefits with other plans with whom you have coverage. Before we can process your claim, we must determine which plan should pay first and which plan should pay second. This is based on specific plan rules. See the Summary Plan Description or detailed information regarding coordination of benefits with other entertainment industry health plans.

It is extremely important that you use your HMO when it is your primary plan.

Yes. You are required to enroll in Medicare Parts A and B when this Health Plan is secondary. If you fail to enroll in Medicare, the Plan's benefits may be reduced or denied

Medicare-Eligible retirees or dependents are required to receive benefits first from Medicare and then from the Trust. In combination, there will be reduction in the overall level of benefits provided to retirees, however, Medicare will provide primary coverage and the OCU Trust will provide secondary coverage. Amounts paid as Medicare Part B monthly premiums will be reimbursed by the Trust consistent with Plan rules

The Board of Trustees has designed a comprehensive program of Health Plan benefits for you and your eligible dependents. However, not all services you receive are covered by the Plan. For covered services, you will be responsible for deductibles, co-payments and co-insurance amounts. You may also be responsible for amounts above the Plan's allowance. If your doctor performs services that the Plan does not cover, you are responsible for the entire bill. It is not the intent of the Health Plan to dictate what type of treatment is appropriate for a patient, nor do we wish to imply that a specific treatment is not beneficial to your condition, but rather that, benefits can only be extended within the provisions and limitations of the Plan.

If a claim has an accident or injury diagnosis, there may be another plan or entity which should provide benefits. If the injury occurred at work, Workers' Compensation would cover the benefits. If a third party is liable for the accident, they would be responsible for the benefits. In all of these cases, we need information from you to determine how your medical expenses should be paid.

Occupational injuries or illnesses are normally covered under Workers' Compensation Insurance. On-the-job injuries or illnesses are not covered by the Health Plan.

Yes. Claims incurred in foreign countries are covered provided that they are as a result of a life threatening injury. The provider may or may not file the claim for you. If you have to pay for services upfront, submit itemized bills to the Trust Fund Office.

No. Any surgery performed to correct a refractive error, such as LASIK, is not covered under the Plan

The Plan will cover nutritional counseling for certain chronic illnesses.

No. There is no Plan benefit for weight loss programs,whether or not they are pursued under medical or physician supervision, unless specifically listed as covered in this plan. This exclusion includes, but is not limited to, commercial weight loss programs (Weight Watchers, Jenny Craig, LA Weight Loss) and fasting programs.

This exclusion does not apply to medically necessary treatments for morbid obesity or dietary evaluations and counseling, and behavioral modification programs for the treatment of anorexia nervosa or bulimia nervosa.

No. Although the Plan will cover durable medical equipment (DME) when prescribed by a doctor, general use items such as an exercise bike are not covered.

Pre-authorizations are required for eyelid, breast and nasal surgeries because these procedures often fall under the cosmetic exclusion. Pre-authorizations are also required for all transplant surgeries, many non-elective surgeries, and many other services. It is always best to contact the Plan Office at least two weeks prior to your proposed surgery.

You must request reconsideration of a fully or partially denied claim within 180 days of the denial of the claim. The request must be in writing, submitted to the Plan Office and accompanied by a statement giving the reasons the denial is believed to be incorrect.

If you visit a network provider, your provider should submit your claim to the appropriate Blue Cross Blue Shield office. Your claim will then be sent to the Health Plan for processing.

If you visit a non-network provider, your provider should submit your claim to the appropriate Blue Cross Blue Shield office. In some cases, you will be required to pay the claim up-front and file the claim with a Blue Cross Blue Shield office. Your claim will then be sent to the Health Plan for processing.

All network and non-network claims must be submitted by one year after the date of service. Each year, a Coordination of Benefits form is mailed to each participant

There is no specific claim form for ASO non-network vision, however, the below standard information must be submitted by either the member or provider. When the provider submits the claim information, the member will be notified via Explanation of Benefits (EOB) once Guardian has processed it.

The claim needs to include the following information along with the itemized bill:

• Name, address and phone number of the out-of-network provider
• Name, address and phone number of the employee
• Employee's member ID
• Name of the plan
• Patient's name, date of birth, address and phone number
• Patient's relationship to the employee

Please submit the Vision claim to:

The Guardian Life Insurance Company of America
PO Box 8007
Appleton WI 54912-8007
Fax: 920-749-7119