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participation agreement, and an out-of-Network provider for other Covered Health Care Services and products.
The participation status of providers will change from time to time.
Network Benefits - the description of how Benefits are paid for Covered Health Care Services provided by
Network providers. The Schedule of Benefits will tell you details about how Network Benefits apply.
Network Pharmacy - a pharmacy that has:

· entered into an agreement with us or an organization contracting on our behalf to provide Prescription
Drug Products to Covered Persons;
· agreed to accept specified reimbursement rates for dispensing Prescription Drug Products; and

· been designated by us as a Network Pharmacy.
New Pharmaceutical Product - a Pharmaceutical Product or new dosage form of a previously approved
Pharmaceutical Product. It applies to the period of time starting on the date the Pharmaceutical Product or new
dosage form is approved by the U.S. Food and Drug Administration (FDA) and ends on the earlier of the following
dates:

· The date it isreviewed.
· December 31st of the following calendar year.

Open Enrollment Period - – thirty days prior to the renewal date of the policy during which Eligible Persons
may enroll themselves and Dependents under the Policy.
Out-of-Network Benefits - the description of how Benefits are paid for Covered Health Care Services provided
by out-of–Network providers. Refer to Section 4, Schedule of Benefits for details about how Out-of-Network
Benefits apply.
Out-of-Pocket Limit - the maximum amount you may pay every Calendar Year. The Schedule of Benefits will tell
you how the Out-of-Pocket Limit applies.
Partial Hospitalization/Day Treatment - a structured ambulatory program. The program may be freestanding or
Hospital-based program and provides services for at least 20 hours per week.

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

Pharmaceutical Product(s) - FDA-approved prescription medication or products administered in connection with
a Covered Health Care Service by a Physician.
Physician - any Doctor of Medicine or Doctor of Osteopathy who is properly licensed and qualified by law.

Note: Any podiatrist, dentist, psychologist, chiropractor, optometrist, or other provider who acts within the scope
of his or her license will be considered on the same basis as a Physician. The fact that we describe a provider as
a Physician does not mean that Benefits for services from that provider are available to you under the Plan.

Plan - the QUEEN CITY SKILLED CARE LLC Medical Plan
Plan Administrator - QUEEN CITY SKILLED CARE LLC or its designee.

Plan Sponsor - QUEEN CITY SKILLED CARE LLC.

Predominant Reimbursement Rate - the charges incurred for a Prescription Drug Product not dispensed at a
member pharmacy that will be considered covered expenses under the Policy. The Predominant Reimbursement
Rate for a particular Prescription Drug Product includes the dispensing fee and sales tax. The Predominant
Reimbursement Rate will be set at the Prescription Drug Product cost that our pharmaceutical benefits manager
and most member pharmacies have agreed to for that Prescription Drug Product.
Prescription Drug Cost - the rate we have agreed to pay our Network Pharmacies, including a dispensing fee
and any applicable sales tax, for a Prescription Drug Product dispensed at a Network Pharmacy.
Prescription Drug List - a list that categorizes into tiers medications, products or devices that have been
approved by the U.S. Food and Drug Administration. This list is subject to our periodic review and modification
(generally twice a year, but no more than six times per Calendar Year). You may determine to which tier a
particular Prescription Drug Product has been assigned through www.myallsavers.com or by calling Customer
Service at the telephone number on your ID card.

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PPO - 2017