Page 2 - Sample EE Benefits Guide

Important Notice

In accordance with the terms of the Employee Retirement Income Security Act of
1974 (ERISA) ABC COMPANY, INC.is including the following statements to comply
with changes in legislation.

• This benefit summary is a summary only. It does not fully describe your
benefit coverage. For details on your benefit coverage, please refer to your
Insurance Company’s Evidence of Coverage. The Evidence of Coverage
is
the binding document between the Health Plan and its members.

• A Health Plan physician must determine that the services and supplies are
medically necessary to prevent, diagnose, or treat your medical condition.
The services and supplies must be provided, prescribed, authorized, or
directed by a Health Plan physician. You must receive the services and
supplies at a Health Plan facility or skilled nursing facility inside your

Insurance Companies Service Area, except where specifically noted to the
contrary in the Evidence of Coverage.

• For details on the benefit and claims review and adjudication procedures,
please refer to Health Plan’s Evidence of Coverage.

If there are any discrepancies between benefits

included in the Summary Plan Description and the

Evidence of Coverage, the Evidence of Coverage

will prevail.