Common use of Individual Coverage Clause in Contracts

Individual Coverage. If you have Individual Coverage, only your own health care expenses are cov­ ered, not the health care expenses of other members of your family. Under Family Coverage, your health care expenses and those of your enrolled spouse and your (and/or your spouse's) enrolled children who are under the limit­ ing age specified in the BENEFIT HIGHLIGHTS section of this Certificate will be covered. All of the provisions of this Certificate that pertain to a spouse also apply to a party of a Civil Union unless specifically noted otherwise. “Child(ren)” used hereafter in this Certificate, means a natural child(ren), a step­ child(xxx), adopted child(xxx), xxxxxx child(xxx), a child(ren) for whom you are the legal guardian or a child(xxx) for whom you have received a court order requiring that you are financially responsible for providing coverage under 26 years of age. a child(xxx) who is in your custody under an interim court order prior to finaliza­ tion of adoption or placement of adoption vesting temporary care, whichever comes first, child(xxx) for whom you are the legal guardian under 26 years of age, regardless of presence or absence of a child's financial dependency, residency, student status, employment status, marital status, eligibility for other coverage or any combination of those factors. In addition, enrolled unmarried children will be covered up to the age of 30 if they: • Live within the service area of the Plan network for this Certificate; and • Have served as an active or reserve member of any branch of the Armed Forces of the United States; and • Have received a release or discharge other than a dishonorable discharge. Coverage for children will end on the last day of the calendar month in which the limiting age birthday falls. If you have Family Coverage, newborn children will be covered from the moment of birth. Please notify the Plan within 31 days of the birth so that your member­ ship records can be adjusted. Your Group Administrator can tell you how to submit the proper notice through the Plan. Children who are under your legal guardianship or who are in your custody under an interim court order prior to finalization of adoption or placement of adoption vesting temporary care, whichever comes first, and xxxxxx children will be cov­ ered. In addition, if you have children for whom you are required by court order to provide health care coverage, those children will be covered. Any children who are incapable of self‐sustaining employment and are dependent upon you or other care providers for lifetime care and supervision because of a disabled condition occurring prior to reaching the limiting age will be covered regardless of age as long as they were covered prior to reaching the limiting age specified in the BENEFIT HIGHLIGHTS section. This coverage does not include benefits for grandchildren (unless such children have been legally adopted or are under your legal guardianship). Coverage under this Certificate is contingent upon timely receipt by the Plan of necessary information and initial premium. A series of federal laws collectively referred to as the ``Medicare Secondary Payer'' (MSP) laws regulate the manner in which certain employers may offer group health care coverage to Medicare eligible employees, spouses, and in some cases, dependent children. Reference to spouse under this section do not include a party to a Civil Union with the Eligible Person or their children. The statutory requirements and rules for MSP coverage vary depending on the basis for Medicare and employer group health plan (“GHP”) coverage, as well as certain other factors, including the size of the employers sponsoring the GHP. In general, Medicare pays secondary to the following:

Individual Coverage. If you have Individual Coverage, only your own health care expenses are cov­ ered, not the health care expenses of other members of your family. Under Family Coverage, your health care expenses and those of your enrolled spouse and your (and/or your spouse's) enrolled children who are under the limit­ ing limiting age specified in the BENEFIT HIGHLIGHTS section of this Certificate will be covered. All of the provisions pro­ visions of this Certificate that pertain to a spouse also apply to a party of a Civil Union unless specifically noted otherwise. “Child(ren)” used hereafter in this Certificate, means a natural child(ren), a step­ child(xxxchild(ren), adopted child(xxx), xxxxxx child(xxxchild(ren), a child(ren) for whom you are the legal guardian or a child(xxx) for whom you have received a court order requiring that you are financially responsible for providing coverage under 26 years of age. a child(xxx) who is in your custody under an interim court order prior to finaliza­ tion finalization of adoption or placement place­ ment of adoption vesting temporary care, whichever comes first, child(xxxchild(ren) for whom you are the legal guardian under 26 years of age, regardless of presence or absence of a child's financial dependency, residency, student status, employment status, marital status, eligibility for other coverage or any combination of those factors. In addition, enrolled unmarried children will be covered up to the age of 30 if they: • Live within the service area of the Plan network for this Certificate; and • Have served as an active or reserve member of any branch of the Armed Forces of the United States; and • Have received a release or discharge other than a dishonorable discharge. Coverage for children will end on the last day of the calendar month in period for which the limiting age birthday fallspremium has been accepted. If you have Family Coverage, newborn children will be covered from the moment of birth. Please notify the Plan within 31 days of the birth so that your member­ ship records can be adjusted. Your Group Administrator can tell you how to submit the proper notice through the Plan. Children who are under your legal guardianship or who are in your custody under an interim court order prior to finalization of adoption or placement of adoption vesting temporary care, whichever comes first, and xxxxxx children will be cov­ ered. In addition, if you have children for whom you are required by court order to provide health care coverage, those children will be covered. Any children who are incapable of self‐sustaining employment and are dependent upon you or other care providers for lifetime care and supervision because of a disabled handicapped condition occurring prior to reaching the limiting age will be covered cov­ ered regardless of age as long as they were covered prior to reaching the limiting age specified in the BENEFIT HIGHLIGHTS section. This coverage does not include benefits for grandchildren (unless such children have been legally adopted or are under your legal guardianship). Coverage under this Certificate is contingent upon timely receipt by the Plan of necessary information and initial premium. A series of federal laws collectively referred to as the ``Medicare Secondary Payer'' (MSP) laws regulate the manner in which certain employers may offer group health care coverage to Medicare eligible employees, spouses, and in some cases, dependent children. Reference to spouse under this section do not include a party to a Civil Union with the Eligible Person or their children. The statutory requirements and rules for MSP coverage vary depending on the basis for Medicare and employer group health plan (“GHP”) coverage, as well as certain other factors, including the size of the employers sponsoring the GHP. In general, Medicare pays secondary to the following:

Individual Coverage. If you have Individual Coverage, only your own health care expenses are cov­ ered, not the health care expenses of other members of your family. Under Family Coverage, your health care expenses and those of your enrolled spouse and your (and/or your spouse's) enrolled children who are under the limit­ ing age specified in the BENEFIT HIGHLIGHTS section of this Certificate will be covered. All of the provisions of this Certificate that pertain to a spouse also apply to a party of a Civil Union unless specifically noted otherwise. A Domestic Partner and his or her children who have not attained the limiting age specified in the BENEFIT HIGHLIGHTS section of this Certificate may also be eligible de­ pendents. All of the provisions of this Certificate that pertain to a spouse also apply to a Domestic Partner unless specifically noted otherwise. “Child(ren)” used hereafter in this Certificate, means a natural child(ren), a step­ child(xxxchild(ren), adopted child(xxx), xxxxxx child(xxxchild(ren), a child(ren) of your Domestic Partner, a child(ren) for whom you are the legal guardian or a child(xxx) for whom you have received a court order requiring that you are financially responsible for providing coverage under 26 years of age. a child(xxx) who is in your custody under un­ der an interim court order prior to finaliza­ tion finalization of adoption or placement of adoption vesting temporary care, whichever comes first, child(xxxchild(ren) for whom you are the legal guardian under 26 years of age, regardless of presence or absence of a child's financial dependency, residency, student status, employment status, marital mar­ ital status, eligibility for other coverage or any combination of those factors. In addition, enrolled unmarried children will be covered up to the age of 30 if they: • Live within the service area of the Plan network for this Certificate; and • Have served as an active or reserve member of any branch of the Armed Forces of the United States; and • Have received a release or discharge other than a dishonorable discharge. Coverage for children will end on the last day of the calendar month in which the limiting age birthday fallsbirthday. If you have Family Coverage, newborn children will be covered from the moment of birth. Please notify the Plan within 31 30 days of the birth so that your member­ ship records can be adjusted. Your Group Administrator can tell you how to submit the proper notice through the Plan. Children who are under your legal guardianship or who are in your custody under an interim court order prior to finalization of adoption or placement of adoption vesting temporary care, whichever comes first, and xxxxxx children will be cov­ ered. In addition, if you have children for whom you are required by court order to provide health care coverage, those children will be covered. Any children who are incapable of self‐sustaining employment and are dependent upon you or other care providers for lifetime care and supervision because of a disabled condition occurring prior to reaching the limiting age will be covered regardless of age as long as they were covered prior to reaching the limiting age specified in the BENEFIT HIGHLIGHTS section. This coverage does not include benefits for grandchildren (unless such children have been legally adopted or are under your legal guardianship). Coverage under this Certificate is contingent upon timely receipt by the Plan of necessary information and initial premium. A series of federal laws collectively referred to as the ``Medicare Secondary Payer'' (MSP) laws regulate the manner in which certain employers may offer group health care coverage to Medicare eligible employees, spouses, and in some cases, dependent children. Reference to spouse under this section do not include a party to a Civil Union with the Eligible Person or Domestic Partners of the Eligi­ ble Person or their children. The statutory requirements and rules for MSP coverage vary depending on the basis for Medicare and employer group health plan (“GHP”) coverage, as well as certain other factors, including the size of the employers sponsoring the GHP. In general, Medicare pays secondary to the following:

Individual Coverage. If you have Individual Coverage, only your own health care expenses are cov­ ered, not the health care expenses of other members of your family. Under Family Coverage, your health care expenses and those of your enrolled spouse and your (and/or your spouse's) enrolled children who are under the limit­ ing age specified in the BENEFIT HIGHLIGHTS section of this Certificate will be covered. All of the provisions of this Certificate that pertain to a spouse also apply to a party of a Civil Union unless specifically noted otherwise. “Child(ren)” used hereafter in this Certificate, means a natural child(ren), a step­ child(xxxchild(ren), adopted child(xxx), xxxxxx child(xxxchild(ren), a child(ren) for whom you are the legal guardian or a child(xxx) for whom you have received a court order requiring that you are financially responsible for providing coverage under 26 years of age. a child(xxx) who is in your custody under an interim court order prior to finaliza­ tion finalization of adoption or placement place­ ment of adoption vesting temporary care, whichever comes first, child(xxxchild(ren) for whom you are the legal guardian under 26 years of age, regardless of presence or absence of a child's financial dependency, residency, student status, employment status, marital status, eligibility for other coverage or any combination of those GB‐16 HCSC 8 factors. In addition, enrolled unmarried children will be covered up to the age of 30 if they: • Live within the service area of the Plan network for this Certificate; and • Have served as an active or reserve member of any branch of the Armed Forces of the United States; and • Have received a release or discharge other than a dishonorable discharge. Coverage for children will end on the last day of the calendar month in period for which the limiting age birthday fallspremium has been accepted. If you have Family Coverage, newborn children will be covered from the moment of birth. Please notify the Plan within 31 days of the birth so that your member­ ship records can be adjusted. Your Group Administrator can tell you how to submit the proper notice through the Plan. Children who are under your legal guardianship or who are in your custody under an interim court order prior to finalization of adoption or placement of adoption vesting temporary care, whichever comes first, and xxxxxx children will be cov­ ered. In addition, if you have children for whom you are required by court order to provide health care coverage, those children will be covered. Any children who are incapable of self‐sustaining employment and are dependent upon you or other care providers for lifetime care and supervision because of a disabled handicapped condition occurring prior to reaching the limiting age will be covered cov­ ered regardless of age as long as they were covered prior to reaching the limiting age specified in the BENEFIT HIGHLIGHTS section. This coverage does not include benefits for xxxxxx children or grandchildren (unless un­ less such children have been legally adopted or are under your legal guardianship). Coverage under this Certificate is contingent upon timely receipt by the Plan of necessary information and initial premium. A series of federal laws collectively referred to as the ``Medicare Secondary Payer'' (MSP) laws regulate the manner in which certain employers may offer group health care coverage to Medicare eligible employees, spouses, and in some cases, dependent children. Reference to spouse under this section do not include a party to a Civil Union with the Eligible Person or their children. The statutory requirements and rules for MSP coverage vary depending on the basis for Medicare and employer group health plan (“GHP”) coverage, as well as certain other factors, including the size of the employers sponsoring the GHP. In general, Medicare pays secondary to the following:

Individual Coverage. If you have Individual Coverage, only your own health care expenses are cov­ ered, not the health care expenses of other members of your family. Under Family Coverage, your health care expenses and those of your enrolled spouse and your (and/or your spouse's) enrolled children who are under the limit­ ing age specified in the BENEFIT HIGHLIGHTS section of this Certificate will be covered. All of the provisions of this Certificate that pertain to a spouse also apply to a party of a Civil Union unless specifically noted otherwise. “Child(ren)” used hereafter in this Certificate, means a natural child(ren), a step­ child(xxxchild(ren), adopted child(xxx), xxxxxx child(xxxchild(ren), a child(ren) for whom you are the legal guardian or a child(xxx) for whom you have received a court order requiring that you are financially responsible for providing coverage under 26 years of age. a child(xxx) who is in your custody under an interim court order prior to finaliza­ tion finalization of adoption or placement place­ ment of adoption vesting temporary care, whichever comes first, child(xxxchild(ren) for whom you are the legal guardian under 26 years of age, regardless of presence or absence of a child's financial dependency, residency, student status, employment status, marital status, eligibility for other coverage or any combination of those factors. In addition, enrolled unmarried children will be covered up to the age of 30 if they: • Live within the service area of the Plan network for this Certificate; and • Have served as an active or reserve member of any branch of the Armed Forces of the United States; and • Have received a release or discharge other than a dishonorable discharge. Coverage for children will end on the last day of the calendar month in which the limiting age birthday falls. If you have Family Coverage, newborn children will be covered from the moment of birth. Please notify the Plan within 31 days of the birth so that your member­ ship records can be adjusted. Your Group Administrator can tell you how to submit the proper notice through the Plan. Children who are under your legal guardianship or who are in your custody under an interim court order prior to finalization of adoption or placement of adoption vesting temporary care, whichever comes first, and xxxxxx children will be cov­ ered. In addition, if you have children for whom you are required by court order to provide health care coverage, those children will be covered. Any children who are incapable of self‐sustaining employment and are dependent upon you or other care providers for lifetime care and supervision because of a disabled handicapped condition occurring prior to reaching the limiting age will be covered cov­ ered regardless of age as long as they were covered prior to reaching the limiting age specified in the BENEFIT HIGHLIGHTS section. This coverage does not include benefits for grandchildren (unless such children have been legally adopted or are under your legal guardianship). Coverage under this Certificate is contingent upon timely receipt by the Plan of necessary information and initial premium. A series of federal laws collectively referred to as the ``Medicare Secondary Payer'' (MSP) laws regulate the manner in which certain employers may offer group health care coverage to Medicare eligible employees, spouses, and in some cases, dependent children. Reference to spouse under this section do not include a party to a Civil Union with the Eligible Person or their children. The statutory requirements and rules for MSP coverage vary depending on the basis for Medicare and employer group health plan (“GHP”) coverage, as well as certain other factors, including the size of the employers sponsoring the GHP. In general, Medicare pays secondary to the following:

Individual Coverage. If you have Individual Coverage, only your own health care expenses are cov­ ered, not the health care expenses of other members of your family. Under Family Coverage, your health care expenses and those of your enrolled spouse and your (and/or your spouse's) enrolled children who are under the limit­ ing age specified in the BENEFIT HIGHLIGHTS section of this Certificate will be covered. All of the provisions of this Certificate that pertain to a spouse also apply to a party of a Civil Union unless specifically noted otherwise. “Child(ren)” used hereafter in this Certificate, means a natural child(ren), a step­ child(xxxchild(ren), adopted child(xxx), xxxxxx child(xxxchild(ren), a child(ren) for whom you are the legal guardian or a child(xxx) for whom you have received a court order requiring that you are financially responsible for providing coverage under 26 years of age. a child(xxx) who is in your custody under an interim court order prior to finaliza­ tion finalization of adoption or placement place­ ment of adoption vesting temporary care, whichever comes first, child(xxxchild(ren) for whom you are the legal guardian under 26 years of age, regardless of presence or absence of a child's financial dependency, residency, student status, employment status, marital status, eligibility for other coverage or any combination of those factors. In addition, enrolled unmarried children will be covered up to the age of 30 if they: • Live within the service area of the Plan network for this Certificate; and • Have served as an active or reserve member of any branch of the Armed Forces of the United States; and • Have received a release or discharge other than a dishonorable discharge. Coverage for children will end on the last day of the calendar calender month in which the limiting age birthday falls. If you have Family Coverage, newborn children will be covered from the moment of birth. Please notify the Plan within 31 days of the birth so that your member­ ship records can be adjusted. Your Group Administrator can tell you how to submit the proper notice through the Plan. Children who are under your legal guardianship or who are in your custody under an interim court order prior to finalization of adoption or placement of adoption vesting temporary care, whichever comes first, and xxxxxx children will be cov­ ered. In addition, if you have children for whom you are required by court order to provide health care coverage, those children will be covered. Any children who are incapable of self‐sustaining employment and are dependent upon you or other care providers for lifetime care and supervision because of a disabled handicapped condition occurring prior to reaching the limiting age will be covered cov­ ered regardless of age as long as they were covered prior to reaching the limiting age specified in the BENEFIT HIGHLIGHTS section. This coverage does not include benefits for grandchildren (unless such children have been legally adopted or are under your legal guardianship). Coverage under this Certificate is contingent upon timely receipt by for unmarried children will end on the Plan last day of necessary information and initial premiumthe calender month in which the limiting age birthday falls. A series of federal laws collectively referred to as the ``Medicare Secondary Payer'' (MSP) laws regulate the manner in which certain employers may offer group health care coverage to Medicare eligible employees, spouses, and in some cases, dependent children. Reference to spouse under this section do not include a party to a Civil Union with the Eligible Person or their children. The statutory requirements and rules for MSP coverage vary depending on the basis for Medicare and employer group health plan (“GHP”) coverage, as well as certain other factors, including the size of the employers sponsoring the GHP. In general, Medicare pays secondary to the following:

Individual Coverage. If you have Individual Coverage, only your own health care expenses are cov­ ered, not the health care expenses of other members of your family. Under Family Coverage, your health care expenses and those of your enrolled spouse and your (and/or your spouse's) enrolled children who are under the limit­ ing age specified in the BENEFIT HIGHLIGHTS section of this Certificate will be covered. All of the provisions of this Certificate that pertain to a spouse also apply to a party of a Civil Union unless specifically noted otherwise. A Domestic Partner and his or her children who have not attained the limiting age specified in the BENEFIT HIGHLIGHTS section of this Certificate may also be eligible de­ pendents. All of the provisions of this Certificate that pertain to a spouse also apply to a Domestic Partner unless specifically noted otherwise. “Child(ren)” used hereafter in this Certificate, means a natural child(ren), a step­ child(xxxchild(ren), adopted child(xxx), xxxxxx child(xxxchild(ren), a child(ren) of your Domestic Partner, a child(ren) for whom you are the legal guardian or a child(xxx) for whom you have received a court order requiring that you are financially responsible for providing coverage under 26 years of age. a child(xxx) who is in your custody under un­ der an interim court order prior to finaliza­ tion finalization of adoption or placement of adoption vesting temporary care, whichever comes first, child(xxxchild(ren) for whom you are the legal guardian under 26 years of age, regardless of presence or absence of a child's financial dependency, residency, student status, employment status, marital mar­ ital status, eligibility for other coverage or any combination of those factors. In addition, enrolled unmarried children will be covered up to the age of 30 if they: • Live within the service area of the Plan network for this Certificate; and • Have served as an active or reserve member of any branch of the Armed Forces of the United States; and • Have received a release or discharge other than a dishonorable discharge. Coverage for children will end on the last day of the calendar month in which the limiting age birthday fallsbirthday. If you have Family Coverage, newborn children will be covered from the moment of birth. Please notify the Plan within 31 days of the birth so that your member­ ship records can be adjusted. Your Group Administrator can tell you how to submit the proper notice through the Plan. Children who are under your legal guardianship or who are in your custody under an interim court order prior to finalization of adoption or placement of adoption vesting temporary care, whichever comes first, and xxxxxx children will be cov­ ered. In addition, if you have children for whom you are required by court order to provide health care coverage, those children will be covered. Any children who are incapable of self‐sustaining employment and are dependent upon you or other care providers for lifetime care and supervision because of a disabled condition occurring prior to reaching the limiting age will be covered regardless of age as long as they were covered prior to reaching the limiting age specified in the BENEFIT HIGHLIGHTS section. This coverage does not include benefits for grandchildren (unless such children have been legally adopted or are under your legal guardianship). Coverage under this Certificate is contingent upon timely receipt by the Plan of necessary information and initial premium. A series of federal laws collectively referred to as the ``Medicare Secondary Payer'' (MSP) laws regulate the manner in which certain employers may offer group health care coverage to Medicare eligible employees, spouses, and in some cases, dependent children. Reference to spouse under this section do not include a party to a Civil Union with the Eligible Person or Domestic Partners of the Eligi­ ble Person or their children. The statutory requirements and rules for MSP coverage vary depending on the basis for Medicare and employer group health plan (“GHP”) coverage, as well as certain other factors, including the size of the employers sponsoring the GHP. In general, Medicare pays secondary to the following:

Individual Coverage. If you have Individual Coverage, only your own health care expenses are cov­ ered, not the health care expenses of other members of your family. Under Family Coverage, your health care expenses and those of your enrolled spouse and your (and/or your spouse's) enrolled children who are under the limit­ ing age specified in the BENEFIT HIGHLIGHTS section of this Certificate will be covered. All of the provisions of this Certificate that pertain to a spouse also apply to a party of a Civil Union unless specifically noted otherwise. A Domestic Partner and his or her children who have not attained the limiting age specified in the BENEFIT HIGHLIGHTS section of this Certificate may also be eligible de­ pendents. All of the provisions of this Certificate that pertain to a spouse also apply to a Domestic Partner unless specifically noted otherwise. “Child(ren)” used hereafter in this Certificate, means a natural child(ren), a step­ child(xxx), adopted child(xxx), xxxxxx child(xxxchild(ren), a child(ren) for whom you are the legal guardian or of your Domestic Partner, a child(xxx) for whom you have received a court order requiring that you are financially responsible for providing coverage under 26 years of age. a child(xxxchild(ren) who is in your custody under an interim court order prior to finaliza­ tion finalization of adoption or placement of adoption vesting temporary care, whichever which­ ever comes first, child(xxx) for whom you are the legal guardian under 26 years of age, regardless of presence or absence of a child's financial dependency, residencyresiden­ cy, student status, employment status, marital status, eligibility for other coverage or any combination of those factors. In addition, enrolled unmarried children will be covered up to the age of 30 if they: • Live within the service area of the Plan network for this Certificate; and • Have served as an active or reserve member of any branch of the Armed Forces of the United States; and • Have received a release or discharge other than a dishonorable discharge. Coverage for children will end on the last day of the calendar month in which the limiting age birthday falls. If you have Family Coverage, newborn children will be covered from the moment of birth. Please notify the Plan within 31 days of the birth so that your member­ ship records can be adjusted. Your Group Administrator can tell you how to submit the proper notice through the Plan. Children who are under your legal guardianship or who are in your custody under an interim court order prior to finalization of adoption or placement of adoption vesting temporary care, whichever comes first, and xxxxxx children will be cov­ ered. In addition, if you have children for whom you are required by court order to provide health care coverage, those children will be covered. Any children who are incapable of self‐sustaining employment and are dependent upon you or other care providers for lifetime care and supervision because of a disabled handicapped condition occurring prior to reaching the limiting age will be covered cov­ ered regardless of age as long as they were covered prior to reaching the limiting age specified in the BENEFIT HIGHLIGHTS section. This coverage does not include benefits for grandchildren (unless such children have been legally adopted or are under your legal guardianship). Coverage under this Certificate is contingent upon timely receipt by the Plan of necessary information and initial premium. A series of federal laws collectively referred to as the ``Medicare Secondary Payer'' (MSP) laws regulate the manner in which certain employers may offer group health care coverage to Medicare eligible employees, spouses, and in some cases, dependent children. Reference to spouse under this section do not include a party to a Civil Union with the Eligible Person or Domestic Partners of the Eligi­ ble Person or their children. The statutory requirements and rules for MSP coverage vary depending on the basis for Medicare and employer group health plan (“GHP”) coverage, as well as certain other factors, including the size of the employers sponsoring the GHP. In general, Medicare pays secondary to the following:

Individual Coverage. If you have Individual Coverage, only your own health care expenses are cov­ ered, not the health care expenses of other members of your family. Under Family Coverage, your health care expenses and those of your enrolled spouse and your (and/or your spouse's) enrolled children who are under the limit­ ing age specified in the BENEFIT HIGHLIGHTS section of this Certificate will be covered. All of the provisions of this Certificate that pertain to a spouse also apply to a party of a Civil Union unless specifically noted otherwise. A Domestic Partner and his or her children who have not attained the limiting age specified in the BENEFIT HIGHLIGHTS section may also be eligible dependents. All of the provisions of this Certificate that pertain to a spouse also apply to a Domestic Partner unless specifically noted otherwise. “Child(ren)” used hereafter in this Certificate, means a natural child(ren), a step­ child(xxx), adopted child(xxx), xxxxxx child(xxxchild(ren), a child(ren) for whom you are the legal guardian or a child(xxx) for whom you have received a court order requiring that you are financially responsible for providing coverage under 26 years of age. your Domestic GB‐16 HCSC 8 Partner, a child(xxx) who is in your custody under an interim court order prior to finaliza­ tion finalization of adoption or placement of adoption vesting temporary care, whichever which­ ever comes first, child(xxx) for whom you are the legal guardian under 26 years of age, regardless of presence or absence of a child's financial dependency, residencyresiden­ cy, student status, employment status, marital status, eligibility for other coverage or any combination of those factors. In addition, enrolled unmarried children will be covered up to the age of 30 if they: • Live within the service area of the Plan network for this Certificate; and • Have served as an active or reserve member of any branch of the Armed Forces of the United States; and • Have received a release or discharge other than a dishonorable discharge. Coverage for children will end on the last day of the calendar month in period for which the limiting age birthday fallspremium has been accepted. If you have Family Coverage, newborn children will be covered from the moment of birth. Please notify the Plan within 31 days of the birth so that your member­ ship records can be adjusted. Your Group Administrator can tell you how to submit the proper notice through the Plan. Children who are under your legal guardianship or who are in your custody under an interim court order prior to finalization of adoption or placement of adoption vesting temporary care, whichever comes first, and xxxxxx children will be cov­ ered. In addition, if you have children for whom you are required by court order to provide health care coverage, those children will be covered. Any children who are incapable of self‐sustaining employment and are dependent upon you or other care providers for lifetime care and supervision because of a disabled handicapped condition occurring prior to reaching the limiting age will be covered cov­ ered regardless of age as long as they were covered prior to reaching the limiting age specified in the BENEFIT HIGHLIGHTS section. This coverage does not include benefits for xxxxxx children or grandchildren (unless un­ less such children have been legally adopted or are under your legal guardianship). Coverage under this Certificate is contingent upon timely receipt by the Plan of necessary information and initial premium. A series of federal laws collectively referred to as the ``Medicare Secondary Payer'' (MSP) laws regulate the manner in which certain employers may offer group health care coverage to Medicare eligible employees, spouses, and in some cases, dependent children. Reference to spouse under this section do not include a party to a Civil Union with the Eligible Person or Domestic Partners of the Eligi­ ble Person or their children. The statutory requirements and rules for MSP coverage vary depending on the basis for Medicare and employer group health plan (“GHP”) coverage, as well as certain other factors, including the size of the employers sponsoring the GHP. In general, Medicare pays secondary to the following:: GB‐16 HCSC 9

Individual Coverage. If you have Individual Coverage, only your own health care expenses are cov­ ered, not the health care expenses of other members of your family. Under Family Coverage, your health care expenses and those of your enrolled spouse and your (and/or your spouse's) enrolled children who are under the limit­ ing age specified in the BENEFIT HIGHLIGHTS section of this Certificate will be covered. All of the provisions of this Certificate that pertain to a spouse also apply to a party of a Civil Union unless specifically noted otherwise. “Child(ren)” used hereafter in this Certificate, means a natural child(ren), a step­ child(xxx), adopted child(xxx), xxxxxx child(xxx), a child(ren) for whom you are the legal guardian or a child(xxx) for whom you have received a court order requiring that you are financially responsible for providing coverage under 26 years of age. a child(xxx) who is in your custody under an interim court order prior to finaliza­ tion of adoption or placement of adoption vesting temporary care, whichever comes first, child(xxx) for whom you are the legal guardian under 26 years of age, regardless of presence or absence of a child's financial dependency, residency, student status, employment status, marital status, eligibility for other coverage or any combination of those factors. In addition, enrolled unmarried children will be covered up to the age of 30 if they: • Live within the service area of the Plan network for this Certificate; and • Have served as an active or reserve member of any branch of the Armed Forces of the United States; and • Have received a release or discharge other than a dishonorable discharge. Coverage for children will end on the last day of the calendar month in period for which the limiting age birthday fallspremium has been accepted. If you have Family Coverage, newborn children will be covered from the moment of birth. Please notify the Plan within 31 days of the birth so that your member­ ship records can be adjusted. Your Group Administrator can tell you how to submit the proper notice through the Plan. Children who are under your legal guardianship or who are in your custody under an interim court order prior to finalization of adoption or placement of adoption vesting temporary care, whichever comes first, and xxxxxx children will be cov­ ered. In addition, if you have children for whom you are required by court order to provide health care coverage, those children will be covered. Any children who are incapable of self‐sustaining employment and are dependent upon you or other care providers for lifetime care and supervision because of a disabled condition occurring prior to reaching the limiting age will be covered regardless of age as long as they were covered prior to reaching the limiting age specified in the BENEFIT HIGHLIGHTS section. This coverage does not include benefits for grandchildren (unless such children have been legally adopted or are under your legal guardianship). Coverage under this Certificate is contingent upon timely receipt by the Plan of necessary information and initial premium. A series of federal laws collectively referred to as the ``Medicare Secondary Payer'' (MSP) laws regulate the manner in which certain employers may offer group health care coverage to Medicare eligible employees, spouses, and in some cases, dependent children. Reference to spouse under this section do not include a party to a Civil Union with the Eligible Person or their children. The statutory requirements and rules for MSP coverage vary depending on the basis for Medicare and employer group health plan (“GHP”) coverage, as well as certain other factors, including the size of the employers sponsoring the GHP. In general, Medicare pays secondary to the following:

Individual Coverage. If you have Individual Coverage, only your own health care expenses are cov­ eredcovered, not the health care expenses of other members of your family. Under Family Coverage, your health care expenses and those of your enrolled spouse and your (and/or your spouse's) enrolled children who are under the limit­ ing limiting age specified in the BENEFIT HIGHLIGHTS section of this Certificate will be covered. All of the provisions of this Certificate that pertain to a spouse also apply to a party of a Civil Union unless specifically noted otherwiseUnion. A Domestic Partner and his or her children who have not attained the limiting age specified in the BENEFIT HIGHLIGHTS section of this Certificate may also be eligible dependents. All of the provisions of this Certificate that pertain to a spouse also apply to a Domestic Partner. “Child(ren)” used hereafter in this Certificate, means a natural child(ren), a step­ child(xxxstepchild(ren), adopted child(xxx), xxxxxx child(xxxchild(ren), a child(ren) of your Domestic Partner, a child(ren) for whom you are the legal guardian or a child(xxx) for whom you have received a court order requiring that you are financially responsible for providing coverage under 26 years of age. , a child(xxx) who is in your custody under an interim court order prior to finaliza­ tion finalization of adoption or placement of adoption vesting temporary care, whichever comes first, child(xxxchild(ren) for whom you are the legal guardian under 26 years of age, regardless of presence or absence of a child's financial dependency, residency, student status, employment status, marital status, eligibility for other coverage or any combination of those factors. In addition, enrolled unmarried children will be covered up to the age of 30 if they: • Live within the service area of the Plan network for this Certificate; and • Have served as an active or reserve member of any branch of the Armed Forces of the United States; and • Have received a release or discharge other than a dishonorable discharge. Coverage for children will end on the last day of the calendar month in which the limiting age birthday falls. If you have Family Coverage, newborn children will be covered from the moment of birth. Please notify the Plan within 31 days of the birth so that your member­ ship records can be adjusted. Your Group Administrator can tell you how to submit the proper notice through the Plan. Children who are under your legal guardianship or who are in your custody under an interim court order prior to finalization of adoption or placement of adoption vesting temporary care, whichever comes first, and xxxxxx children will be cov­ ered. In addition, if you have children for whom you are required by court order to provide health care coverage, those children will be covered. Any children who are incapable of self‐sustaining employment and are dependent upon you or other care providers for lifetime care and supervision because of a disabled condition occurring prior to reaching the limiting age will be covered regardless of age as long as they were covered prior to reaching the limiting age specified in the BENEFIT HIGHLIGHTS section. This coverage does not include benefits for grandchildren (unless such children have been legally adopted or are under your legal guardianship). Coverage under this Certificate is contingent upon timely receipt by the Plan of necessary information and initial premium. A series of federal laws collectively referred to as the ``Medicare Secondary Payer'' (MSP) laws regulate the manner in which certain employers may offer group health care coverage to Medicare eligible employees, spouses, and in some cases, dependent children. Reference to spouse under this section do not include a party to a Civil Union with the Eligible Person or their children. The statutory requirements and rules for MSP coverage vary depending on the basis for Medicare and employer group health plan (“GHP”) coverage, as well as certain other factors, including the size of the employers sponsoring the GHP. In general, Medicare pays secondary to the following:

Individual Coverage. If you have Individual Coverage, only your own health care expenses are cov­ eredcovered, not the health care expenses of other members of your family. Under Family Coverage, your health care expenses and those of your enrolled spouse and your (and/or your spouse's) enrolled children who are under the limit­ ing limiting age specified in the BENEFIT HIGHLIGHTS section of this Certificate will be covered. All of the provisions of this Certificate that pertain to a spouse also apply to a party of a Civil Union unless specifically noted otherwise. A Domestic Partner and his or her children who have not attained the limiting age specified in the BENEFIT HIGHLIGHTS section of this Certificate may also be eligible dependents. All of the provisions of this Certificate that pertain to a spouse also apply to a Domestic Partner unless specifically noted otherwise. “Child(ren)” used hereafter in this Certificate, means a natural child(ren), a step­ child(xxxstepchild(ren), adopted child(xxx), xxxxxx child(xxxchild(ren), a child(ren) of your Domestic Partner, a child(ren) for whom you are the legal guardian or a child(xxx) for whom you have received a court order requiring that you are financially responsible for providing coverage under 26 years of age. a child(xxx) who is in your custody under an interim court order prior to finaliza­ tion finalization of adoption or placement of adoption vesting temporary care, whichever comes first, child(xxx) for whom you are the legal guardian under 26 years of age, regardless of presence or absence of a child's financial dependency, residency, student status, employment status, marital status, eligibility for other coverage or any combination of those factors. In addition, enrolled unmarried children will be covered up to the age of 30 if they: • Live within the network service area of the Plan network for this Certificate; and • Have served as an active or reserve member of any branch of the Armed Forces of the United States; and • Have received a release or discharge other than a dishonorable discharge. Coverage for children will end on the last day of the calendar month in which the limiting age birthday falls. If you have Family Coverage, newborn children will be covered from the moment of birth. Please notify the Plan within 31 days of the birth so that your member­ ship membership records can be adjusted. Your Group Administrator can tell you how to submit the proper notice through the Plan. Children who are under your legal guardianship or who are in your custody under an interim court order prior to finalization of adoption or placement of adoption vesting temporary care, whichever comes first, and xxxxxx children will be cov­ eredcovered. In addition, if you have children for whom you are required by court order to provide health care coverage, those children will be covered. Any children who are incapable of self‐sustaining employment and are dependent upon you or other care providers Providers for lifetime care and supervision because of a disabled condition occurring prior to reaching the limiting age will be covered regardless of age as long as they were covered prior to reaching the limiting age specified in the BENEFIT HIGHLIGHTS section. This coverage does not include benefits for grandchildren (unless such children have been legally adopted or are under your legal guardianship). Coverage under this Certificate is contingent upon timely receipt by the Plan of necessary information and initial premium. A series of federal laws collectively referred to as the ``Medicare Secondary Payer'' (MSP) laws regulate the manner in which certain employers may offer group health care coverage to Medicare eligible employees, spouses, and in some cases, dependent children. Reference to spouse under this section do not include a party to a Civil Union with the Eligible Person or Domestic Partners of the Eligible Person or their children. The statutory requirements and rules for MSP coverage vary depending on the basis for Medicare and employer group health plan (“GHP”) coverage, as well as certain other factors, including the size of the employers sponsoring the GHP. In general, Medicare pays secondary to the following:

Individual Coverage. If you have Individual Coverage, only your own health care expenses are cov­ eredcovered, not the health care expenses of other members of your family. Under Family Coverage, your health care expenses and those of your enrolled spouse and your (and/or your spouse's) enrolled children who are under the limit­ ing age specified in the BENEFIT HIGHLIGHTS section of this Certificate will be covered. All of the provisions of this Certificate that pertain to a spouse also apply to a party of a Civil Union unless specifically noted otherwise. A Domestic Partner and his or her children who have not attained the limiting age specified in the BENEFIT HIGHLIGHTS section of this Certificate may also be eligible de­ pendents, provided your Employer covers Domestic Partners. All of the provisions of this Certificate that pertain to a spouse also apply to a Domestic Partner unless specifically noted otherwise, provided your Employer covers Do­ mestic Partners. “Child(ren)” used hereafter in this Certificate, means a natural child(ren), a step­ child(xxxstepchild(ren), adopted child(xxxchild(ren), xxxxxx child(xxxchild(ren), a child(ren) for whom you are the legal guardian or of your Domestic Partner (provided your Employer covers Domestic Partners), a child(xxx) for whom you have received a court order requiring that you are financially responsible for providing coverage under 26 years of age. a child(xxxchild(ren) who is in your custody under an interim court order prior to finaliza­ tion finalization of adoption or placement of adoption vesting temporary care, whichever comes first, a child(ren) of your child(ren), grandchild(ren), child(xxx) for whom you are the legal guardian under 26 years of age, regardless of presence or absence of a child's financial dependencyde­ pendency, residency, student status, employment status, marital status, eligibility for other coverage or any combination of those factors. In addition, enrolled unmarried unmar­ ried children will be covered up to the age of 30 if they: • Live within the service area of the Plan network for this Certificate; and • Have served as an active or reserve member of any branch of the Armed Forces of the United States; and • Have received a release or discharge other than a dishonorable discharge. Coverage for children will end on the last day of the calendar month in period for which the limiting age birthday fallspremium has been accepted. If you have Family Coverage, newborn children will be covered from the moment of birth. Please notify the Plan within 31 days of the birth so that your member­ ship records can be adjusted. Your Group Administrator can tell you how to submit the proper notice through the Plan. Children who are under your legal guardianship or who are in your custody under an interim court order prior to finalization of adoption or placement of adoption vesting temporary care, whichever comes first, and xxxxxx children will be cov­ eredcovered. In addition, if you have children for whom you are required by court order or­ der to provide health care coverage, those children will be covered. Any children who are incapable of self‐sustaining employment and are dependent upon you or other care providers for lifetime care and supervision because of a disabled handicapped condition occurring prior to reaching the limiting age will be covered regardless of age as long as they were covered prior to reaching the limiting age specified in the BENEFIT HIGHLIGHTS sectionlimit­ ing age. This coverage does not include benefits for grandchildren (unless such children have been legally adopted or are under your legal guardianship). Coverage under this Certificate is contingent upon timely receipt by the Plan of necessary information and initial premium. A series of federal laws collectively referred to as the ``Medicare Secondary PayerPay­ er'' (MSP) laws regulate the manner in which certain employers Employers may offer group health care coverage to Medicare eligible employees, spouses, and in some cases, dependent children. Reference to spouse under this section do not include a party to a Civil Union with the Eligible Person or the Domestic Partner (provided your Employer covers Domestic Partners) of the Eligible Person or their children. The statutory requirements and rules for MSP coverage vary depending on the basis for Medicare and employer group health plan (“GHP”) coverage, as well as certain other factors, including the size of the employers sponsoring the GHP. In general, Medicare pays secondary to the following:

Individual Coverage. If you have Individual Coverage, only your own health care expenses are cov­ ered, not the health care expenses of other members of your family. Under Family Coverage, your health care expenses and those of your enrolled spouse and your (and/or your spouse's) enrolled children who are under the limit­ ing age specified in the BENEFIT HIGHLIGHTS section of this Certificate will be covered. All of the provisions of this Certificate that pertain to a spouse also apply to a party of a Civil Union unless specifically noted otherwise. “Child(ren)” used hereafter in this Certificate, means a natural child(ren), a step­ child(xxxchild(ren), adopted child(xxx), xxxxxx child(xxxchild(ren), a child(ren) for whom you are the legal guardian or a child(xxx) for whom you have received a court order requiring that you are financially responsible for providing coverage under 26 years of age. , a child(xxx) who is in your custody under an interim court order prior to finaliza­ tion of adoption or placement of adoption vesting temporary care, whichever comes first, child(xxx) for whom you are the legal guardian under 26 years of age, regardless of presence or absence of a child's financial dependency, residency, student status, employment status, marital status, eligibility for other coverage or any combination of those factors. In addition, enrolled unmarried children will be covered up to the age of 30 if they: • Live within the service area of the Plan network for this Certificate; and • Have served as an active or reserve member of any branch of the Armed Forces of the United States; and • Have received a release or discharge other than a dishonorable discharge. Coverage for children will end on the last day of the calendar calender month in which the limiting age birthday falls. If you have Family Coverage, newborn children will be covered from the moment of birth. Please notify the Plan within 31 days of the birth so that your member­ ship records can be adjusted. Your Group Administrator can tell you how to submit the proper notice through the Plan. Children who are under your legal guardianship or who are in your custody under an interim court order prior to finalization of adoption or placement of adoption vesting temporary care, whichever comes first, and xxxxxx children will be cov­ ered. In addition, if you have children for whom you are required by court order to provide health care coverage, those children will be covered. Any children who are incapable of self‐sustaining employment and are dependent upon you or other care providers for lifetime care and supervision because of a disabled condition occurring prior to reaching the limiting age will be covered regardless of age as long as they were covered prior to reaching the limiting age specified in the BENEFIT HIGHLIGHTS section. This coverage does not include benefits for grandchildren (unless such children have been legally adopted or are under your legal guardianship). Coverage under this Certificate is contingent upon timely receipt by the Plan of necessary information and initial premium. A series of federal laws collectively referred to as the ``Medicare Secondary Payer'' (MSP) laws regulate the manner in which certain employers may offer group health care coverage to Medicare eligible employees, spouses, and in some cases, dependent children. Reference to spouse under this section do not include a party to a Civil Union with the Eligible Person or their children. The statutory requirements and rules for MSP coverage vary depending on the basis for Medicare and employer group health plan (“GHP”) coverage, as well as certain other factors, including the size of the employers sponsoring the GHP. In general, Medicare pays secondary to the following:

Individual Coverage. If you have Individual Coverage, only your own health care expenses are cov­ eredcovered, not the health care expenses of other members of your family. Under Family Coverage, your health care expenses and those of your enrolled spouse and your (and/or your spouse's) enrolled children who are under the limit­ ing age specified in the BENEFIT HIGHLIGHTS section of this Certificate will be covered. All of the provisions of this Certificate that pertain to a spouse also apply to a party of a Civil Union unless specifically noted otherwise. A Domestic Partner and his or her children who have not attained the limiting age specified in the BENEFIT HIGHLIGHTS section of this Certificate may also be eligible de­ pendents, provided your Employer covers Domestic Partners. All of the provisions of this Certificate that pertain to a spouse also apply to a Domestic Partner unless specifically noted otherwise, provided your Employer covers Do­ mestic Partners. “Child(ren)” used hereafter in this Certificate, means a natural child(ren), a step­ child(xxxchild(ren), adopted child(xxxchild(ren), xxxxxx child(xxxchild(ren), a child(ren) for whom you are the legal guardian or of your Domestic Partner (provided your Employer covers Domestic Partners), a child(xxx) for whom you have received a court order requiring that you are financially responsible for providing coverage under 26 years of age. a child(xxxchild(ren) who is in your custody under an interim court order prior to finaliza­ tion finalization of adoption or placement of adoption vesting temporary care, whichever comes first, a child(ren) of your child(ren), grandchild(ren), child(xxx) for whom you are the legal guardian under 26 years of age, regardless of presence or absence of a child's financial dependencyde­ pendency, residency, student status, employment status, marital status, eligibility for other coverage or any combination of those factors. In addition, enrolled unmarried un­ married children will be covered up to the age of 30 if they: • Live within the service area of the Plan network for this Certificate; and • Have served as an active or reserve member of any branch of the Armed Forces of the United States; and • Have received a release or discharge other than a dishonorable discharge. Coverage for children will end on the last day of the calendar month in period for which the limiting age birthday fallspremium has been accepted. If you have Family Coverage, newborn children will be covered from the moment of birth. Please notify the Plan within 31 days of the birth so that your member­ ship records can be adjusted. Your Group Administrator can tell you how to submit the proper notice through the Plan. Children who are under your legal guardianship or who are in your custody under an interim court order prior to finalization of adoption or placement of adoption vesting temporary care, whichever comes first, and xxxxxx children will be cov­ eredcovered. In addition, if you have children for whom you are required by court order to provide health care coverage, those children will be covered. IL‐G‐H‐OF‐2016 14 Any children who are incapable of self‐sustaining employment and are dependent upon you or other care providers for lifetime care and supervision because of a disabled handicapped condition occurring prior to reaching the limiting age will be covered cov­ ered regardless of age as long as they were covered prior to reaching the limiting age specified in the BENEFIT HIGHLIGHTS sectionage. This coverage does not include benefits for grandchildren (unless such children have been legally adopted or are under your legal guardianship). Coverage under this Certificate is contingent upon timely receipt by the Plan of necessary information and initial premium. A series of federal laws collectively referred to as the ``“Medicare Secondary Payer'' Pay­ er” (MSP) laws regulate the manner in which certain employers Employers may offer group health care coverage to Medicare eligible employees, spouses, and in some cases, dependent children. Reference to spouse under this section do not include a party to a Civil Union with the Eligible Person or the Domestic Partner (provided your Employer covers Domestic Partners) of the Eligible Person or their children. The statutory requirements and rules for MSP coverage vary depending on the basis for Medicare and employer group health plan (“GHP”) coverage, as well as certain other factors, including the size of the employers sponsoring the GHP. In general, Medicare pays secondary to the following:

Individual Coverage. If you have Individual Coverage, only your own health care expenses are cov­ eredcovered, not the health care expenses of other members of your family. Under Family Coverage, your health care expenses and those of your enrolled spouse and your (and/or your spouse's) enrolled children who are under the limit­ ing limiting age specified in the BENEFIT HIGHLIGHTS section of this Certificate will be covered. All of the provisions of this Certificate that pertain to a spouse also apply to a party of a Civil Union unless specifically noted otherwise. “Child(ren)” used hereafter in this Certificate, means a natural child(ren), a step­ child(xxxstepchild(ren), adopted child(xxx), xxxxxx child(xxxchild(ren), a child(ren) for whom you are the legal guardian or a child(xxx) for whom you have received a court order requiring that you are financially responsible for providing coverage under 26 years of age. , a child(xxxchild(ren) who is in your custody under an interim court order prior to finaliza­ tion finalization of adoption or placement of adoption vesting temporary care, whichever comes first, child(xxxchild(ren) for whom you are the legal guardian under 26 years of age, regardless of presence or absence of a child's financial dependency, residency, student status, employment status, marital status, eligibility for other coverage or any combination of those factors. In addition, enrolled unmarried children will be covered up to the age of 30 if they: • Live within the network service area of the Plan network for this Certificate; and • Have served as an active or reserve member of any branch of the Armed Forces of the United States; and • Have received a release or discharge other than a dishonorable discharge. Coverage for children will end on the last day of the calendar month in which the the limiting age birthday falls. If you have Family Coverage, newborn children will be covered from the moment of birth. Please notify the Plan within 31 days of the birth so that your member­ ship membership records can be adjusted. Your Group Administrator can tell you how to submit the proper notice through the Plan. Children who are under your legal guardianship or who are in your custody under an interim court order prior to finalization of adoption or placement of adoption vesting temporary care, whichever comes first, and xxxxxx children will be cov­ eredcovered. In addition, if you have children for whom you are required by court order to provide health care coverage, those children will be covered. Any children who are incapable of self‐sustaining employment and are dependent upon you or other care providers Providers for lifetime care and supervision because of a disabled condition occurring prior to reaching the limiting age will be covered regardless of age as long as they were covered prior to reaching the limiting age specified in the BENEFIT HIGHLIGHTS section. This coverage does not include benefits for grandchildren (unless such children have been legally adopted or are under your legal guardianship). Coverage under this Certificate is contingent upon timely receipt by the Plan of necessary information and initial premium. A series of federal laws collectively referred to as the ``Medicare Secondary Payer'' (MSP) laws regulate the manner in which certain employers may offer group health care coverage to Medicare eligible employees, spouses, and in some cases, dependent children. Reference to spouse under this section do not include a party to a Civil Union with the Eligible Person or their children. The statutory requirements and rules for MSP coverage vary depending on the basis for Medicare and employer group health plan (“GHP”) coverage, as well as certain other factors, including the size of the employers sponsoring the GHP. In general, Medicare pays secondary to the following: