Page 14 - Open Sky BROCHURE - HOURLY 2021-2022

Physician shall provide such benefits with durational limits, deductibles, coinsurance factors, and Copayments that are no
less favorable than for physical Illness generally.

Patient Protection Disclosure

The group health plan or health insurance issuer generally requires the designation of a primary care provider if enrolling in
a Health Maintenance Organization (HMO) plan. You have the right to designate any primary care provider who participates in
the network and who is available to accept you or your family members. If you do not make this designation, the group health
plan or health insurance issuer will designate one for you or your family members. You have the right to change your provider
for any reason. For information on how to select a primary care provider, and for a list of the participating primary care
providers, contact the Plan Administrator. For children, you may designate a pediatrician as the primary care provider.

You do not need prior authorization from the group health plan or issuer or from any other person (including a primary care
provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who
specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain
procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures
for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the
Plan Administrator.

Notice of Special Enrollment Rights

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance
or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents
lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other
coverage). However, you must request enrollment no later than 30 days after your or your dependents’ other coverage ends (or
after the employer stops contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able
to enroll yourself and your dependents. However, you must request enrollment no later than 30 days after the marriage, birth,
adoption, or placement for adoption.

Effective April 1, 2009, if either of the following two events occur, you will have 60 days from the date of the event to request
enrollment in your employer’s plan:

• Your dependents lose Medicaid or CHIP coverage because they are no longer eligible.
• Your dependents become eligible for a state’s premium assistance program.

To take advantage of special enrollment rights, you must experience a qualifying event and provide the employer plan with
timely notice of the event and your enrollment request.

To request special enrollment or obtain more information, contact the Plan Administrator.

Qualified Medical Child Support Order Procedures

What is a Qualified Medical Child Support Order (QMCSO)?

A “QMCSO” is a medical child support order (from a court or administrative agency) that creates or recognizes the
right of an “alternate recipient” to receive benefits for which a participant or beneficiary is eligible under a group
health plan. It is recognized by the group health plan as “qualified” because it includes information and meets other
requirements.

Who can be an “alternate recipient”?

Any child of a participant in a group health plan who is recognized under a medical child support order as having a
right to enrollment under the plan with respect to such participant is an alternate recipient.

What information must a medical child support order contain to be a “qualified” order?