FAMILY SUPPLEMENTAL BENEFIT

You and your eligible dependents may be reimbursed up to $1,500 each calendar year for medically necessary services that are not covered under the Plan. You must submit all paid receipts, itemized bills, and Explanation of Benefits (EOBs) for the expenses with a Family Supplemental Benefit Claim form no later than one year from date of service. The $1,500 maximum is for the family.

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Some of the expenses that can be reimbursed include non-covered services (except for maximums and expenses covered at 50%), such as:

• Routine vision exams,
• Prescription eye glasses and contact lenses,
• Corrective vision surgery for vision,
• Hearing aids,
• Routine physical exams for children over the age of two,
• Certain limited prescriptions, and
• Orthodontia treatment for adults.

Also reimbursable are charges over the Plan maximums benefits, this which includes:

• Member and spouse routine physical expenses over the calendar year maximum,
• Dependent children under age two over the $2,000 lifetime well child maximum,
• Children’s orthodontia treatment over the $2,000 lifetime maximum (treatment started after 1/1/09), and
• Dental expenses over the $1,000 calendar year maximum.

Expenses that are not reimbursable include, but are not limited to:

• Deductibles,
• Copayments,
• Expenses exceeding reasonable and customary expenses charges,
• Non-allowed Medicare expenses,
• Weight loss programs,
• Smoking cessation expenses,
• Core blood storage,
• Health club or exercise programs,
• Jacuzzi’s,
• School expenses for children, and
• Cosmetic procedures.