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Employee - a full-time Employee of the Employer who meets the eligibility requirements specified in the Plan, as
described under Eligibility in Section 2, Introduction. An Employee must live and/or work in the United States.

Employee Retirement Income Security Act of 1974 (ERISA) - the federal legislation that regulates retirement
and employee welfare benefit programs maintained by employers and unions.
Employer - QUEEN CITY SKILLED CARE LLC

Enrolled Dependent - a Dependent who is covered under the Plan.
Experimental or Investigational Service(s) - medical, surgical, diagnostic, psychiatric, mental health,
substance-related and addictive disorders or other health care services, technologies, supplies, treatments,
procedures, drug therapies, medications or devices that, at the time the Claims Administrator makes a
determination regarding coverage in a particular case, are determined to be any of the following:

· not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed
use and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia
Dispensing Information as appropriate for the proposed use;

· subject to review and approval by any institutional review board for the proposed use. (Devices which are
FDA approved under the Humanitarian Use Device exemption are not Experimental or Investigational); or
· the subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial described
in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight.
Exceptions:

· Clinical trials for which Benefits are available as described under Clinical Trials in Section 5, Additional
Coverage Details.
· We may, as we determine, consider an otherwise Experimental or Investigational Service to be a
Covered Health Care Service for that Sickness or condition if:
· You are not a participant in a qualifying clinical trial, as described under Clinical Trials in Section
1: Covered Health Care Services; and

· You have a Sickness or condition that is likely to cause death with one year of the request for
treatment.

Freestanding Facility - an outpatient, diagnostic or ambulatory center or independent laboratory which performs
services and submits claims separately from a Hospital.
Gene Therapy - therapeutic delivery of nucleic acid (DNA or RNA) into a patient's cells as a drug to treat a
disease.
Genetic Counseling - counseling by a qualified clinician that includes:

· Identifying your potential risks for suspected genetic disorders;
· An individualized discussion about the benefits, risks and limitations of Genetic Testing to help you make
informed decisions about Genetic Testing; and

· Interpretation of the Genetic Testing results in order to guide heal decisions.
Certified genetic counselors, medical geneticists and physicians with a professional society's certification that they
have completed advanced training in genetics are considered qualified clinicians when Covered Health Care
Services for Genetic Testing require Genetic Counseling.
Genetic Testing - exam of blood or other tissue for changes in genes (DNA or RNA) that may indicate an
increased risk for developing a specific disease or disorder, or provide information to guide the selection of
treatment of certain diseases, including cancer.
Generic - a Prescription Drug Product:

· that is Chemically Equivalent to a Brand-name drug; or
· that we identify as a Generic product based on available data resources including, but not limited to, First
DataBank, that classify drugs as either brand or generic based on a number of factors.

Page 82 Section 15 - Glossary
PPO - 2017