Summary of Benefits This Summary of Benefits shows the amount you will pay for covered services under this Blue Shield of California plan. It is only a summary and it is part of the contract for health care coverage, called the Evi- dence of Coverage (EOC). Please read both documents carefully for details. ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE INDEPENDENCE AND SAFE MOBILITY WITH AAA - Your benefit is provided by American Automobile Associ- ation of Northern California, Nevada & Utah (AAA). The benefit is a Classic AAA membership and includes access to Independent and Safe Mobility tools and services. • Roadwise Driver • Educational Driving Resources • Roadside Assistance $0 First $250 each Calendar Year $250 Remainder of charges 20% plus 100% of additional charges over the $50,000 lifetime maximum BASIC GYM ACCESS THROUGH SILVERSNEAKERS® FITNESS $0 HEARING AID SERVICES – Your hearing aid services benefits are provided by EPIC Hearing Healthcare (EPIC). This benefit is designed for you to use EPIC network providers. EPIC Participating Providers are listed at xxxxxxxxxxxx.xxx/XxxxxxxXxxx. If you choose to use out-of-network providers, those services will not be covered. This benefit is separate from diagnostic hearing examinations and related charges as covered by Medi- care. Hearing aid benefits every year include: • One routine hearing exam • Hearing aid instrument o Choice of private-labeled Silver (mid-level) or Gold (premium level) tech- nology hearing aid models o Up to two hearing aids in the following styles: ▪ in-the-ear; ▪ in-the-canal; ▪ completely-in-canal; ▪ behind-the-ear; or ▪ receiver-in-the-ear. o All technology levels include: ▪ one consultation; ▪ two-year supply of batteries per hearing aid; and ▪ three-year extended warranty. o Silver technology level hearing aids include: ▪ one behind-the-ear hearing aid (non-ear mold model) delivered directly to your home; and $0 Silver Technology Level: $449 per hearing aid Gold Technology Level: $699 per hearing aid ▪ up to three virtual follow-up visits by a participating provider for hearing aid fitting, consultation, device check, and adjustment for no additional cost. o Gold technology level hearing aids include: ▪ one hearing aid delivered in-person by a participating provider; ▪ up to three in-person follow-up visits for hearing aid fitting, con- sultation, device check, and adjustment for no additional cost; and ▪ standard ear molds & impressions. ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE VISION SERVICES– Your vision benefits are provided by Vision Service Plan (VSP). This benefit offers one of the largest national network of independent doctors located in retail, neighborhood, medical and professional settings. You can lower any out-of-pocket costs by choosing network providers for covered services. VSP Participating Providers may be located through an online directory at xxxxxxxxxxxx.xxx. Click on Find a Doctor. Comprehensive eye exam once every 12 months $20 All costs above $50 Eyeglass frame once every 24 months All costs above $100 All costs above $40 Eyeglass lenses once every 12 months $25 Single vision: • Single vision• Bifocal• Trifocal• Aphakic or lenticular monofocal or multifocal All costs above $43 Bifocal:All costs above $60 Trifocal: All costs above $75 Aphakic or lenticular monofo- cal or multifocal: All costs above $104 Contact lenses (instead of eyeglass lenses) once every 12 months • Non-elective (medically necessary) – Hard or Soft – one pair • Elective (cosmetic/convenience) – Hard – one pair • Elective (cosmetic/convenience) – Soft – Up to a three- to six-month supply for each eye based on lenses selected Non-elective (hard or soft): $25 copay and all costs above $500 Elective (hard or soft): $25 copay and all costs above $120 Non-elective (hard or soft): All costs above $200 Elective (hard or soft): All costs above $100 ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE PHYSICIAN CONSULTATION BY PHONE OR VIDEO THROUGH TELADOC $0 per consult OVER-THE-COUNTER ITEMS THROUGH CVS – Eligible over-the-counter (OTC) items are available through the OTC Items Catalog, at xxx.xxxxxxxxxxxx.xxx/xxxxxxxxXXX. Limitations may apply. Refer to the OTC Items Catalog for more information. Up to two orders per quarter All costs above the $100 Allow- ance per quarter No person has the right to receive the benefits of this plan for Services furnished following termination of coverage except as specifically provided under the extension of benefits, Part I.B. of this Agreement. Benefits of this plan are available only for Services furnished during the term it is in effect and while the individual claiming benefits is actually covered by this Agreement. Benefits may be modified during the term of this plan as specifically provided under the terms of this Agreement or upon renewal. If benefits are modified, the revised benefits (including any reduction in benefits or the elimination of benefits) apply to Services furnished on or after the effective date of the modification. There is no vested right to receive the benefits of this Agree- ment. I: CONDITIONS OF COVERAGE AND PAYMENT OF DUES
Timing of Plan Administrator Response The Plan Administrator shall respond in writing to such claimant within 60 days after receiving the request for review. If the Plan Administrator determines that special circumstances require additional time for processing the claim, the Plan Administrator can extend the response period by an additional 60 days by notifying the claimant in writing, prior to the end of the initial 60-day period, that an additional period is required. The notice of extension must set forth the special circumstances and the date by which the Plan Administrator expects to render its decision.
Form and Timing of Severance Benefits The Severance Benefits described in Sections 3.3(a), 3.3(b), and 3.3
Timing of Release of Claims Whenever in this Agreement a payment or benefit is conditioned on the Executive’s execution and non-revocation of a release of claims, such as the separation agreement referenced in Section 11(a) hereof, such release must be executed and all revocation periods shall have expired within 60 days after the Date of Termination; failing which such payment or benefit shall be forfeited. If such payment or benefit constitutes Non-Exempt Deferred Compensation, then, subject to subsection (c) above, such payment or benefit (including any installment payments) that would have otherwise been payable during such 60-day period shall be accumulated and paid on the 60th day after the Date of Termination provided such release shall have been executed and such revocation periods shall have expired. If such payment or benefit is exempt from Section 409A of the Code, the Company may elect to make or commence payment at any time during such 60-day period.
Change in Form or Timing of Distributions All changes in the form or timing of distributions hereunder must comply with the following requirements. The changes: (a) may not accelerate the time or schedule of any distribution, except as provided in Section 409A of the Code and the regulations thereunder; (b) must, for benefits distributable under Sections 2.1, 2.2, 2.3 and 2.4, delay the commencement of distributions for a minimum of five (5) years from the date the first distribution was originally scheduled to be made; and (c) must take effect not less than twelve (12) months after the election is made.
Timing of Response Intermediary agrees to execute instructions as soon as reasonably practicable, but not later than five business days after receipt of the instructions by the Intermediary.
Timing of Company Response The Company shall respond to such claimant within 90 days after receiving the claim. If the Company determines that special circumstances require additional time for processing the claim, the Company can extend the response period by an additional 90 days by notifying the claimant in writing, prior to the end of the initial 90-day period, that an additional period is required. The notice of extension must set forth the special circumstances and the date by which the Company expects to render its decision.
Timing of Severance Payments Any severance payment to which Employee is entitled under Sections 3(a)(i)(1), 3(a)(i)(2) and 3(a)(i)(5) shall be paid by the Company to the Employee (or to the Employee's successors in interest pursuant to Section 7(b)) in cash and in full, not later than thirty (30) calendar days following the Termination Date, subject to any delay required under Section 9.
Timing of Reimbursements and In-kind Benefits If Executive is entitled to be paid or reimbursed for any taxable expenses under this Agreement, and such payments or reimbursements are includible in Executive’s federal gross taxable income, the amount of such expenses reimbursable in any one calendar year shall not affect the amount reimbursable in any other calendar year, and the reimbursement of an eligible expense must be made no later than December 31 of the year after the year in which the expense was incurred. No right of Executive to reimbursement of expenses under this Agreement shall be subject to liquidation or exchange for another benefit.
Timing of Administrator Response The Administrator shall respond to such Claimant within ninety (90) days after receiving the claim. If the Administrator determines that special circumstances require additional time for processing the claim, the Administrator can extend the response period by an additional ninety (90) days by notifying the Claimant in writing, prior to the end of the initial ninety (90) day period, that an additional period is required. The notice of extension must set forth the special circumstances and the date by which the Administrator expects to render its decision.
