Page 85 - QCS.19 SPD - PPO

Cosmetic Procedures - procedures or services that change or improve appearance without significantly
improving physiological function, as determined by the Claims Administrator.
Covered Health Care Service(s) - health care services, including supplies or Pharmaceutical Products, which we
determine to be all of the following:
· Provided for the purpose of preventing, evaluating, diagnosing or treating of a Sickness, Injury, Mental
Illness, substance-related and addictive disorders, condition, disease or symptoms;

· Incurred while you and your Dependent are covered by the plan;
· Prescribed, ordered, recommended or approved by an authorized health care provider;

· Medically Necessary;
· Not subject to an applicable limitation or exclusion; and

· Allowed under all other applicable terms and conditions of the Plan.
The Plan does not pay for that part of a Covered Health Care Service which:

· Is subject to a Copayment, Annual Deductible, Coinsurance or penalty; or
· Exceeds an applicable benefit maximum; or

· Is not an Allowed Amount.
Covered Person - either the Subscriber or an Enrolled Dependent, but this term applies only while the person is
enrolled under the Plan. References to "you" and "your" throughout this Plan are references to a Covered Person.
Custodial Care - services that are any of the following:

· Non-health-related services, such as assistance in activities of daily living (examples include feeding,
dressing, bathing, transferring and ambulating);
· Health-related services that can safely and effectively be performed by trained non-medical personnel
and are provided for the primary purpose of meeting the personal needs of the patient or maintaining a
level of function, as opposed to improving that function to an extent that might allow for more independent
existence.

Definitive Drug Test - tests to identify specific medications, illicit substances and metabolites and is qualitative
and quantitative to identify possible use of a drug.
Dependent - the Subscriber's legal Spouse or a child of the Subscriber or the Subscriber's Spouse. The term
child includes any of the following:
· A natural child;

· A stepchild;
· A legally adopted child;

· A child placed for adoption; and
· A child for whom legal guardianship has been awarded to the Subscriber or the Subscriber's Spouse.

To be eligible for coverage under the Plan, a Dependent must reside within the United States.
The definition of Dependent is subject to the following conditions and limitations:

· A Dependent includes any child listed above under 26 years of age;
· A Dependent includes an unmarried dependent child age 26 or older who is or becomes disabled and
dependent upon the Subscriber.

The Subscriber must reimburse the Plan for any Benefits paid for a child at a time when the child did not satisfy
these conditions.

Page 80 Section 15 - Glossary
PPO - 2017