Medical Summary Plan Description

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Medical

Summary Plan Description

About This Summary Plan Description (SPD)

We are pleased to provide the Tenet Medical Benefit Program, which offers health coverage to eligible employees and their eligible Dependents. The Tenet Medical Benefit Program is a component program in the Tenet Employee Benefit Plan (TEBP), a comprehensive welfare benefits plan intended to qualify as a cafeteria plan within the meaning of Internal Revenue Code (IRC) Section 115. Under the Tenet Medical Benefit Program, you may select one of the following medical care options:

 Health and Savings Plan

 Health & Reimbursement Plan

 PPO

 EPO

This document summarizes key provisions of the Tenet Medical Benefit Program and the medical care options listed above, and it serves as part of the Summary Plan Description (SPD) for the TEBP. You can obtain more information about the Medical Benefit Program, the TEBP, and the other component programs offered under the TEBP by viewing the complete SPD for the TEBP. If there is any discrepancy between the TEBP SPD (including this Medical Benefit Program section) and the official plan documents (including collective bargaining agreements, if any) for the TEBP, the official plan documents will

govern. For more information on obtaining the official plan documents, see theOther Information

section of the TEBP SPD.

The TEBP SPD is designed to meet your information needs and the disclosure requirements of the Employee Retirement Income Security Act of 1974 (ERISA). It supersedes any previous printed or electronic SPD for the TEBP. It does not serve as a contract of or for employment.

Tenet Healthcare Corporation and its subsidiaries and affiliates who have adopted the TEBP are

referred to in this SPD as “Tenet,” “Employer,” or “Company.” Capitalized words in this Medical Benefit Program section of the TEBP have special meaning and are defined below under “Glossary.” The words “you” and “your” as used in this Medical Benefit Program section refer to “Covered Persons” (as defined in the Glossary).

You should read this entire SPD section carefully and share it with your family. This Medical Benefit Program section of the TEBP SPD includes summaries of:

 Who is eligible for the Medical Benefit Program

 Services that are covered under the Medical Benefit Program options, called Covered Health

Services

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How to Use This SPD

 Read the entire SPD, and share it with your family.

 Many of the sections of this SPD are related to other sections. You may not have all the

information you need by reading just one section.

 You can access this SPD and any future amendments on this site or request printed copies by

contacting the MyBenefits Customer Support Center at 1-877-468-3638.

 Capitalized words in the SPD have special meaning and are defined in the Glossary.

 If eligible for coverage, the words "you" and "your" refer to Covered Persons as defined in the Glossary.

 Tenet Healthcare Corporation is also referred to as Company.

Introduction to the Medical Benefit Program

This section of the SPD includes:

 Quick Facts: Who You Can Cover, Cost of Coverage, When Coverage Begins, and When Coverage

Ends

 The factors that impact your cost of coverage

 Instructions and timeframes for enrolling yourself and your eligible Dependents in the Medical

Benefit Program

 When you can make coverage changes under the Medical Benefit Program.

Quick Facts

Who You Can

Cover



Employee and eligible Dependents 

Cost of Coverage



You and Tenet share the cost of your medical coverage.

When Coverage Begins



On the 31st day after you begin employment in a full-time or part-time

benefit eligible position, provided you’ve enrolled. For an explanation of benefit eligible employees, see the definition of “Benefit Eligible” in the

Glossary below and theEligibility and Enrollmentsection of this TEBP SPD.



Coverage for your Dependents will start on the date your coverage begins,

provided you have enrolled them in a timely manner.



Coverage for newly eligible Dependents begins on the date they become

eligible and Dependent documentation has been received and verified (through birth, adoption, etc.), provided you enroll them within 31 days (as

applicable, see theLife Eventssection of the TEBP SPD for more information)

of the date they become eligible.

When Coverage Ends



When coverage ends is dependent on various factors. Please refer to When

Coverage Ends below, and in theEligibility and Enrollmentsection of the

TEBP SPD, for detailed information on when coverage for you and your Dependents ends.



In some circumstances, you or your Dependents may be eligible to continue

your medical coverage under the Consolidated Omnibus Budget

Reconciliation Act (COBRA) of 1985, as amended. For more information on

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Cost of Coverage

You and Tenet share in the cost of the Medical Benefit Program. Your contribution amount depends on the medical care option you select and the family members you choose to enroll.

Your contributions are typically deducted from your paychecks on a before-tax basis. Before-tax dollars come out of your pay before federal income and Social Security taxes are withheld - and in most states, before state and local taxes are withheld. This gives your contributions a special tax advantage and lowers the actual cost to you. Your contributions for Domestic Partner coverage will be deducted from your paychecks on an after-tax basis unless your Domestic Partner qualifies as your federal tax

dependent within the meaning of IRC section 152 (determined without regard to IRC sections

152(b)(1), (b)(2), and (d)(1)(B)) . For more information in determining whether your Domestic Partner qualifies as your federal tax Dependent, contact your tax advisor.

Your contributions are subject to review and Tenet reserves the right to change your contribution amount from time to time.

You can obtain current contribution rates by calling the MyBenefits Customer Support Center at

1-877-468-3638 or accessing your personal enrollment information fromHealthyatTenet.com.

How to Enroll

1. Enroll online atHealthyatTenet.comor call the MyBenefits Customer Support Center at

1-877-468-3638.

2. Complete an enrollment transaction within 31 days of the date you first become eligible for coverage under the Tenet Medical Benefit Program. If you do not enroll within 31 days, you will need to wait to make your benefit elections until the next Annual Enrollment period or the date you incur a change of family status or HIPAA special enrollment event entitling you to a mid-year enrollment. For more information on change of family status and HIPAA special enrollment events,

see theLife Eventssection of the TEBP SPD.

Each year during Annual Enrollment, you have the opportunity to review, change, or cancel your healthcare coverage. All changes made during the Annual Enrollment period will take effect on January 1 of the following calendar year.

Important

If you wish to change your benefit elections following your marriage, birth or adoption of a child, or other family status change or HIPAA special enrollment event, you must complete your enrollment

transaction online atHealthyatTenet.comor call the MyBenefits Customer Support Center at

1-877-468-3638 within 31 days of the event and request your change. Otherwise, you will need to wait until the next Annual Enrollment period to change your elections.

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How the Medical Benefit Program Works

This section includes information on:

 Network and out-of-network benefits

 Gap Exceptions  Eligible Expenses  Annual Deductible  Co-Insurance  Out-of-Pocket Maximum

Network Benefits

As a participant in the Medical Benefit Program, you have the freedom to choose the Physician or health care professional you prefer each time you need to receive Covered Health Services. The choices you make affect the amounts you pay, as well as the level of Benefits you receive and any benefit limitations that may apply.

You are eligible for the network level of Benefits under this Plan when you receive Covered Health Services from Physicians and other health care professionals who are Network Providers. Network Providers are those that are contracted with the network(s) indicated on the identification card. For all Covered Health Services, Network Providers must accept a reduced rate (“Negotiated Rate”) as their charge for services rendered and cannot bill for the difference between the charge and the Negotiated Rate.

All Tenet facilities will be Network Providers and are generally reimbursed at a higher reimbursement level than contracted Network providers unless you apply for and receive a network gap exception as noted below.

Keep in mind, a Provider’s status as a Network Provider may change. To verify a Provider’s status as a Network Provider or to request a Network Provider directory, you can call member services at the

toll-free number on your ID card or use the My Benefits links from the home page ofHealthyatTenet.com.

Generally, when you receive Covered Health Services from a Network Provider, you pay less than you would if you receive the same care from an Out-of-Network Provider. Therefore, in most instances, your out-of-pocket expenses will be less if you use a Network Provider.

Out-of-Network Benefits

Payment for Covered Health Services rendered by an Out-of-Network Provider will be based on the Provider’s Reasonable and Customary (R&C) Charge. The Out-of-Network Provider may bill for charges in excess of the R&C Charge, and such amounts will be your responsibility. Covered Health Services provided by Out-of-Network Providers will generally be covered at a lower benefit level than services received from a Network Provider (unless the services provided by the Out-of-Network Provider qualify for a higher payment level because of the Network Gap Exception, described below), and any amounts not covered by the Tenet Medical Benefit Program will be your responsibility. These amounts could be significant and will not count towards your Pocket Maximum. You may want to ask an Network Provider about its charges before you receive care. Emergency services received at an Out-of-Network Hospital will be covered at the same level as if they were incurred in network.

Network Gap Exception

Network Gap Exceptions should be proactively requested by the Employee. The Network Gap Exception process is available in the following circumstances:

 If the services are not available at a Tenet facility

 The service is available at a Tenet facility, but your specific medical needs cannot be met (a medical

management review is required)

 You do not live within 45 miles of a Tenet facility

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Out-of-Network Exception Process

 Claims are to be Pre-Certified prior to the service.

 You should call the carrier to request an authorization to see an Out-of-Network Provider.

 You should be able to inform the Claims Administrator if this is a one-time visit, or if there will be ongoing treatment.

 The Claims Administrator will search within a 45-mile radius from your home to determine if a

Network Provider can be located.

o If a Network Provider is found within the 45-mile radius, the Employee will be instructed to see

the Network Provider for in-network benefits. The Out-of-Network Provider will not be authorized for in-network benefits, and if the Employee chooses to see the Out-of-Network Provider regardless, benefits will be paid at the lower Out-of-Network levels.

o If no Network Provider is found within the 45-mile radius, and the requested Out-of-Network

Provider has a valid tax id number, the Claims Administrator will authorize the visits, and benefits will be paid at the Network Provider level.

o If a valid Taxpayer ID number is not given, then the Provider’s information should be obtained,

so that an out bound call can be made to the Provider to obtain the necessary information. If an Employee receives services from an Out-of-Network Provider and he or she feels that the claim should be considered as in-network, the Employee should call member services at the toll-free number on their ID card and speak with the Claims Administrator and request an appeal.

Outpatient Dialysis Covered Services

Notwithstanding anything in this SPD section to the contrary, the Tenet Medical Benefit Program bases its benefit payments (under all three medical care options offered by the Medical Benefit Program) for covered outpatient dialysis-related services and products on the “Outpatient Dialysis Reasonable and Customary Charge” (as defined herein), rather than the Negotiated Rate for Network Providers and the R&C Charge for Out-of-Network Providers. With respect to any outpatient dialysis charge (either in network or Out-of-Network), the Tenet Medical Benefit Program will pay no more than the Outpatient Dialysis Reasonable and Customary Charge, after deduction of all amounts subject to Deductible, Co-insurance, or applicable Co-payments. Refer to the benefit description of Kidney Dialysis for further details.

Eligible Expenses

Eligible Expenses are charges for Covered Health Services (provided while you are covered under the Tenet Medical Benefit Program) that are determined in accordance with the definition in the Glossary. For certain Covered Health Services, the Plan will not pay for any Eligible Expenses until you have met your Annual Deductible. See below for more information on the Annual Deductible. We have delegated to the Claims Administrator the initial discretion and authority to decide whether a treatment or supply

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Don’t Forget Your Medical ID Card

Remember to show your medical ID card every time you receive health care services from a Provider. If you do not show your ID card, a Provider has no way of knowing that you are enrolled under the Plan.

Annual Deductible

The Annual Deductible is the amount you must pay each calendar year for Covered Health Services before the Tenet Medical Benefit Program begins paying benefits. For medical coverage options providing benefits for both Network and Out-of-Network services, there are separate Network and Out of Network Annual Deductibles, and expenses applied to one deductible do not count towards the other. (For example, any expenses applied to your Network deductible do not also apply to your Out-of-Network Deductible.) The amounts you pay toward your Annual Deductible accumulate over the course of the calendar year.

You and your covered family members will need to meet the Annual Deductible every calendar year. Each medical care option under the Medical Benefit Program offers a family deductible, so you never have to pay more than the annual family deductible for that option, regardless of how many family members you’ve enrolled in the Medical Benefit Program.

Certain services are not subject to the Annual Deductibles. See“Medical Benefit Program Options:

Highlights”for more information.

Co-insurance

Co-insurance is the percentage of Eligible Expenses that you are responsible for paying. Co-insurance is a fixed percentage that applies to certain Covered Health Services after you meet the Annual

deductible. Not all Covered Health Services are subject to a co-insurance requirement. See“Medical

Benefit Program Options: Highlights”for more information. Co-insurance — Example

Example: Let’s assume that you receive Benefits for a Physician’s office visit from a Network Provider. Since your Medical Benefit Program pays 80% after you meet the Annual Deductible, you are responsible for paying the other 20%. This 20% is your Co-insurance.

Out-of-Pocket Maximum

The annual Out-of-Pocket Maximum is the most you pay each calendar year for Covered Health Services provided by a Network Provider. If your network eligible out-of-pocket expenses in a calendar year exceed the Out-of Pocket Maximum, the Medical Benefit Program pays 100% of your Eligible Expenses for Covered Health Services through the end of the calendar year.

Covered Expenses charged by Network Providers apply toward both the network individual and family Out-of-Pocket Maximums.

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The following identifies what does not apply toward your Network Out-of-Pocket Maximum:

 Co-insurance and/or co-pays and related fees for using Out-of-Network Providers

 Amounts you pay that are above the R&C Charge for an Out-of-Network service

 Co-insurance when you don’t follow the required notification review procedures

 Deductibles and co-payments for prescription drugs under the Retail Prescription Drug Card

Program and Mail Order Program (except Health & Savings Plan)

Medical Benefit Program Options: Highlights

This section of the SPD includes tables describing the Annual Deductibles, Out-of-Pocket Maximums, co-pays, and Co-insurance rates that apply when you receive certain Covered Health Services under the Health & Savings Plan, Health & Reimbursement Plan, PPO and EPO options.

Please see“Plan Coverage Details”for more information (including restrictions, limitations and prior

authorization/notification requirements) pertaining to the Benefits offered under the medical care options listed above.

Notes:

1. The purpose of this section is to provide highlights of the Tenet Employee Benefit Plan. If there is any

discrepancy between the information provided and the official TEBP and Medical Benefit Program plan documents, the official plan documents will govern.

2. Not all Medical Benefit Program options are offered at all locations. Please contact your HR representative

to determine the options offered at your location.

3. Certain provisions for employees covered by collective bargaining agreements are referenced in the

Appendix.

4. For specific information on the prescription drug coverage offered under each Medical Benefit Program

option, see thePrescription DrugBenefit Program SPD section of the TEBP.

Non-Union Medical Plans

NON UNION - Health & Savings Plan

Category In-Network Out-of-Network

Annual Deductible

The combined charges of all family members are applied toward the satisfaction of this cumulative deductible amount. Deductible will apply to Out-of-Pocket Maximums.

$1,250 Employee Only

$2,500 Employee + Spouse, Child or Family

Prescription drug expenses apply toward the deductible

$2,400 Employee Only $4,800 Employee + Spouse, Child or Family

Annual Out-of-Pocket

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NON UNION - Health & Savings Plan

(continued)

Preventive Services

oWell-child care

oAdult physical

oWell-woman exam

oMammography

You pay $0 You pay full cost

Inpatient Hospital

Services Tenet facility: FREE after deductible *_{Non-Tenet, gap exception: You pay}

20% after deductible

Non-Tenet, no gap exception: You

pay 70% after deductible

You pay 75% after deductible

Outpatient Hospital

Services Tenet facility: FREE after deductible *Non-Tenet, gap exception: You pay

Maternity Care

oPrenatal care

Tenet-employed physician: Ask your

local HR

Tenet-preferred physician: You pay

Non-Tenet-employed physician: You

pay 20% after deductible _{You pay 75% after deductible}

oHospital delivery Tenet facility: FREE after deductible *

Non-Tenet, gap exception: You pay

Emergency Care

oEmergency room

services

$100 ER fee (waived if admitted)

Tenet facility: FREE after deductible * Non-Tenet facility: You pay 10% after

deductible

$100 ER fee (waived if admitted) You pay 10% after deductible

oAmbulance You pay 20% after deductible You pay 20% after deductible

Other Services

oAcupuncture /

chiropractic care (a)

oOutpatient physical /

occupational / speech therapy (b)

local HR

Tenet-preferred physician: You pay

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NON UNION - Health & Savings Plan

(continued)

Other Services (continued)

oHome health care (c)

oDurable medical

equipment

You pay 20% after deductible You pay 75% after deductible

oSkilled nursing (b) Tenet facility: FREE after deductible *

Mental Health / Substance Abuse

oInpatient

oOutpatient

oOffice Visit

You pay 10% after deductible * You pay 75% after deductible

* You will receive the greatest benefit coverage when services are provided at a Tenet facility.

If you are enrolled in the Health & Savings Plan and receive care at a Tenet facility, the co-insurance is waived by the facility. These waiver benefits are not part of the official Tenet Employee Benefit Plan and are not reflected on statements from the medical carrier. The adjustment will be noted on the invoice from the health care provider. For information about Tenet discount policies, refer to Policy AD2.06.

Gap exception. Participants must obtain approval from the carrier before receiving services at a non-Tenet facility in order to

receive a gap exception. Call the Member Services number on your medical ID card. Gap exceptions may be approved if services are not available at a Tenet facility within 45 miles of your home; or if it is an emergency admission; or if services are available at a Tenet facility within 45 miles of your home but your specific medical needs cannot be met (medical management review is required).

(a) 20 visits per calendar year (b) 60 visits per calendar year (c) 120 visits per calendar year

NON-UNION - Health & Reimbursement Plan

This type of family deductible is the summation of all amounts applied to individual deductible. In the event only one family member has eligible medical expenses, only one

$1,600 per person $3,200 family maximum

Prescription drug expenses do not

$3,200 per person $6,400 maximum

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NON-UNION - Health & Reimbursement Plan

(continued)

Physician Care

oOffice visit

oIP/OP/ER

oLab/X-ray

employed and/or Tenet-preferred physician: Ask your

local HR

Non-Tenet-employed physician:

oWell-child care

oAdult physical

oWell-woman exam

oMammography

Inpatient Hospital Services Tenet facility: FREE *

Non-Tenet, gap exception: You

Outpatient Hospital Services Tenet facility: FREE *

Maternity Care

oPrenatal care

local HR

oHospital delivery Tenet facility: FREE *

Emergency Care

oEmergency room services $100 ER fee (waived if admitted)

Tenet facility: FREE *

Non-Tenet facility: You pay 10%

after deductible

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NON-UNION – Health & Reimbursement Plan

(continued)

Other Services oAcupuncture / chiropractic care (a) oOutpatient physical / occupational / speech therapy (b)

local HR

oDurable medical equipment You pay 20% after deductible You pay 75% after deductible

oSkilled nursing (b) Tenet facility: FREE *

Mental Health / Substance Abuse

oInpatient

oOutpatient

oOffice Visit

You pay 10% * You pay 75% after deductible

If you are enrolled in the Health & Reimbursement Plan and receive care at a Tenet facility, the deductible does not apply and co-insurance is waived by the facility. These waiver benefits are not part of the official Tenet Employee Benefit Plan and are not reflected on statements from the medical carrier. The adjustment will be noted on the invoice from the health care provider. For information about Tenet discount policies, refer to Policy AD2.06.

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Union Medical Plans

(except Cypress Fairbanks Nurses)

UNION - Health & Savings Plan

The combined charges of all family members are applied toward the satisfaction of this cumulative deductible amount. Deductible will apply to Out-of-Pocket Maximums.

$1,250 Employee Only

$2,500 Employee + Spouse, Child or Family

$2,400 Employee Only $4,800 Employee + Spouse, Child or Family

Maximum $5,200 Employee Only_{$10,400 Employee + Spouse, Child or}

Family Unlimited Physician Care oOffice visit oIP/OP/ER oLab/X-ray

local HR

oWell-child care

oAdult physical

oWell-woman exam

oMammography

Inpatient Hospital

Outpatient Hospital

Maternity Care

oPrenatal care

local HR

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UNION - Health & Savings Plan

(continued)

Maternity Care (continued)

oHospital delivery

Tenet facility: FREE after deductible * Non-Tenet, gap exception: You pay

Emergency Care

oEmergency room

services

Tenet facility: FREE after deductible * Non-Tenet facility: You pay 10% after

deductible

$100 ER fee (waived if admitted) You pay 10% after deductible

Other Services

oAcupuncture /

chiropractic care (a)

oOutpatient physical /

occupational / speech therapy (b)

local HR

oDurable medical

equipment You pay 20% after deductible You pay 60% after deductible

oSkilled nursing (b) Tenet facility: FREE after deductible *

Mental Health / Substance Abuse

oInpatient

oOutpatient

oOffice visit

You pay 10% after deductible * You pay 60% after deductible

If you are enrolled in the Health & Savings Plan and receive care at a Tenet facility, the co-insurance is waived by the facility. These waiver benefits are not part of the official Tenet Employee Benefit Plan and are not reflected on statements from the medical carrier. The adjustment will be noted on the invoice from the health care provider. For information about Tenet discount policies, refer to Policy AD2.06.

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UNION - Health & Reimbursement Plan

This type of family deductible is the summation of all amounts applied to individual deductible. In the event only one family member has eligible medical expenses, only one individual deductible would have to be satisfied. Deductible will apply to Out-of-Pocket Maximums.

Prescription drug expenses do not apply toward the deductible

$3,200 per person $6,400 family maximum Prescription drug expenses do not apply toward the

deductible

Annual Out-of-Pocket Maximum

$5,200 per person

$10,400 family maximum No maximum

Physician Care

oOffice visit

oIP/OP/ER

oLab/X-ray

Tenet-employed physician: Ask

your local HR

oWell-child care

oAdult physical

oWell-woman exam

oMammography

Maternity Care

oPrenatal care

your local HR

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UNION - Health & Reimbursement Plan

(continued)

Emergency Care

oEmergency room services

after deductible

your local HR

oInpatient

oOutpatient

oOffice visit

If you are enrolled in the Health & Reimbursement Plan and receive care at a Tenet facility, the deductible does not apply and co-insurance is waived by the facility. These waiver benefits are not part of the official Tenet Employee Benefit Plan and are not reflected on statements from the medical carrier. The adjustment will be noted on the invoice from the health care provider. For information about Tenet discount policies, refer to Policy AD2.06.

(a) 20 visits per calendar year (b) 60 visits per calendar year

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UNION - PPO

This type of family deductible is the summation of all amounts applied to individual deductible. In the event only one family member has eligible medical expenses, only one individual deductible would have to be satisfied. Deductible will apply to Out-of-Pocket Maximums.

$800 per person $2,400 family maximum

$1,600 per person $4,800 family maximum Prescription drug expenses do not apply toward the

deductible

Maximum $4,000 per person_{$12,000 family maximum} No maximum Physician Care

oOffice visit

oIP/OP/ER

oLab/X-ray

your local HR

oWell-child care

oAdult physical

oWell-woman exam

oMammography

Maternity Care

oPrenatal care

your local HR

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UNION - PPO

(continued)

Emergency Care

after deductible

your local HR

oInpatient

oOutpatient

oOffice visit

If you are enrolled in the PPO and receive care at a Tenet facility, the deductible does not apply and co-insurance is waived by the facility. These waiver benefits are not part of the official Tenet Employee Benefit Plan and are not reflected on statements from the medical carrier. The adjustment will be noted on the invoice from the health care provider. For information about Tenet discount policies, refer to Policy AD2.06.

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UNION - EPO

Category In-Network Only (No out-of network benefits)

Deductible for EPO will only apply to non-Tenet inpatient or outpatient hospital services when services are available at Tenet.

$800 per person $2,400 family maximum

Annual Out-of-Pocket Maximum

Out-of-Pocket Maximums for EPO will only apply to non-Tenet inpatient or outpatient hospital services when services are available at Tenet.

Physician Care

oOffice visit

oIP/OP/ER

Tenet-employed physician: Ask your local HR

Non-Tenet-employed physician / specialist: You pay $30 / $45

co-pay per visit

oLab/X-ray Tenet free-standing facility: FREE *

Non-Tenet free-standing facility: You pay $30 co-pay per visit Non-Tenet-employed physician / specialist office: You pay $30

/ $45 co-pay if performed on day other than office visit

Preventive Services oWell-child care oAdult physical oWell-woman exam oMammography You pay $0

Non-Tenet, gap exception: You pay $500 co-pay per

admission

Non-Tenet, no gap exception: You pay 50% after deductible Outpatient Hospital Services Tenet facility: FREE *

admission

Non-Tenet, no gap exception: You pay 50% after deductible Maternity Care

oPrenatal care

Non-Tenet-employed physician / specialist: You pay $30 / $45

co-pay per visit (initial visit only)

admission

Non-Tenet, no gap exception: You pay 50% after deductible Emergency Care

You pay $100 ER fee (waived if admitted)

Contracted facility: You pay 10% after deductible

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UNION - EPO

Category In-Network Only (No out-of network benefits)

Other Services

oAcupuncture/chiropractic care (a)

oOutpatient physical/ occupational/

speech therapy (b)

Non-Tenet-employed physician: You pay $45 co-pay per visit

oDurable medical equipment You pay $0

admission

Non-Tenet, no gap exception: You pay 50% after deductible Mental Health

oInpatient You pay $500 per admission *

oOutpatient You pay $250 per admission *

oOffice visit You pay $45 per visit *

If you are enrolled in the EPO and receive care at a Tenet facility, the deductible does not apply and co-insurance is waived by the facility. These waiver benefits are not part of the official Tenet Employee Benefit Plan and are not reflected on statements from the medical carrier. The adjustment will be noted on the invoice from the health care provider. For information about Tenet discount policies, refer to Policy AD2.06.

Note: Participants must notify Claims Administrator before receiving services at a non-Tenet facility. The Claims Administrator can be reached by calling the Member Services number on your Medical ID card. Carrier can authorize payment at the higher benefit level, but only in the following situations: 1) if the services are not available at a Tenet facility, 2) if you do not live within 45 miles of a Tenet facility, 3) if it is an emergency admission or 4) if the service is available at a Tenet facility, but your specific medical needs cannot be met (medical management review is required). All other services received at a non-Tenet facility will be subject to the lower benefit level.

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Plan Coverage Details

This section includes information on:

 Covered Health Services for which the Plan pays Benefits; and

 Covered Health Services that require you to notify the Claims Administrator before you receive

them, and any reduction in Benefits that may apply if you do not call the Claims Administrator. Services that are not covered by any medical care option offered under the Tenet Medical Benefit Program are described in the Exclusions section.

Acupuncture Services

The Medical Benefit Program pays for Acupuncture Services for pain therapy provided that the service is performed in a Provider’s office by a Provider who is either practicing within the scope of his/her license (if state license is available) or who is certified by a national accrediting body such as one of the following:

 Doctor of Medicine

 Doctor of Osteopathy

 Chiropractor, or

 Acupuncturist

The Medical Benefit Program also pays for Acupuncture services for treatment of nausea as a result of:

 Chemotherapy

 Early Pregnancy, and

 Post-operative procedures

Benefits for Acupuncture and Chiropractic Care combined are limited to 20 visits per calendar year.

Ambulance Services — Emergency Only

The Plan covers Emergency Ambulance Services and transportation provided by a licensed Ambulance

Service to the nearest Hospital that offers Emergency health services. See the“Glossary”for the

definition of Emergency.

Ambulance Service by air is covered in an Emergency if ground transportation is impossible, or would put your life or health in serious jeopardy. If special circumstances exist, the Claims

Administrator may, at the Plan’s discretion, pay Benefits for Emergency air transportation to a Hospital that is not the closest Facility to provide Emergency health services.

Chiropractic Care

The Medical Benefit Program pays Benefits for Chiropractic Treatment (at the level described in Medical Benefit Program Options: Highlights) when provided by a Network or Out-of-Network Chiropractic specialist in the specialist’s office. Covered Health Services include chiropractic and osteopathic manipulative therapy.

The Claims Administrator has the right to deny Benefits if treatment ceases to be therapeutic and is instead administered to maintain a level of functioning or to prevent a medical problem from occurring or recurring.

Benefits include diagnosis and related services. Benefits for Acupuncture and Chiropractic combined are limited to a maximum of 20 visits per calendar year.

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Dental Services

In certain circumstances dental services are covered under the Medical Benefit Program. For services covered under the Dental Benefit Program please see theDentalBenefit Program Section.

 Dental services are covered by the Tenet Medical Benefit Program (as “office visits” or inpatient or

outpatient care, as appropriate) when all of the following are true:

o Treatment is necessary because of accidental damage to a sound, natural tooth

o Dental damage does not occur as a result of normal activities of daily living or extraordinary use

of the teeth

o Dental services are received from a Doctor of Dental Surgery or a Doctor of Medical Dentistry,

and

o The dental damage is severe enough that initial contact with a Physician or dentist occurs

within 72 hours of the accident

The following dental services are also covered by the Medical Benefit Program:

 Dental transplant preparation

 Initiation of immunosuppressives (medication used to reduce inflammation and suppress the

immune system), and

 Direct treatment of acute traumatic Injury, cancer or cleft palate

Before the Medical Benefit Program will cover treatment of an injured tooth, the dentist must certify that the tooth is virgin or unrestored, and that it:

 Has no decay

 Has no filling on more than two surfaces

 Has no gum disease associated with bone loss

 Has no root canal therapy

 Is not a dental implant, and

 Functions normally in chewing and speech

Dental services for final treatment to repair the damage must be started within three months of the accident and completed within 12 months of the accident.

Please contact your Claims Administrator for any questions related to your coverage.

Durable Medical Equipment (DME)

The Medical Benefit Program pays for Durable Medical Equipment (DME) that is:

 Ordered or provided by a Physician for outpatient use

 Used for medical purposes

 Not consumable or disposable

 Not of use to a person in the absence of a Sickness, Injury, Pregnancy or disability

 Durable enough to withstand repeated use, and

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Examples of DME include but are not limited to:

 Insulin Pump

 Equipment to administer oxygen

 Wheelchairs

 Hospital beds

 Delivery pumps for tube feedings

 Braces that straighten or change the shape of a body part

 Braces that stabilize an injured body part, including necessary adjustments to shoes to

accommodate braces

 Equipment for the treatment of chronic or acute respiratory failure or conditions

 Ostomy supplies, and

 Shoe orthotics

The Plan also covers tubings, nasal cannulas, connectors and masks used in connection with DME

Note: DME is different from prosthetic devices — see“Prosthetic Devices”in this section.

Benefits for wigs are limited to $1,000 per covered person per lifetime.

Benefits are provided for the replacement of a type of Durable Medical Equipment once every three calendar years.

Please remember

For Out-of-Network Benefits, you must notify the claims administrator if the purchase, rental, repair or replacement of DME will cost more than $1,000.

Emergency Health Services

The Medical Benefit Programs covers outpatient Emergency treatment at a Hospital or Alternate Facility when required to stabilize a patient or initiate treatment due to a Medical Emergency.

As used herein, a Medical Emergency is a serious medical condition or symptom resulting from Injury, Sickness, Pregnancy, mental illness, or substance abuse which arises suddenly and in the judgment of a reasonable person, requires immediate care and treatment, generally received within 24 hours of onset, to avoid jeopardy to life or health.

Emergency care in the emergency department of a Hospital will not be covered unless the condition is determined to be a Medical Emergency.

If you are admitted as an inpatient to a Hospital within 24 hours of receiving treatment for an Emergency Health Service, you will not have to pay the Fee for Emergency Health Services. However, you will be required to pay the Deductible, Co-insurance and/or co-pay amount if any, for your Emergency treatment as well as any of the above amounts applicable to your Inpatient Stay in the Hospital.

If you are admitted to an out-of-network hospital and your physician determines that it is medically appropriate to transfer you to a network Hospital, your Benefits for the Inpatient Stay from that date will be paid at the Out-of-Network level.

Hearing Care

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Home Health Care

Covered Health Services are services that a Home Health Agency provides if you are homebound due to the nature of your condition. Services must be:

 Ordered by a Physician

 Provided by or supervised by a registered nurse in your home

 Not considered Custodial Care, as defined in the Glossary, and

 Provided on a part-time, intermittent schedule when Skilled Home Health Care is required. Refer to

the Glossary for the definition of Skilled Home Health Care

The Claims Administrator will decide if Skilled Home Health Care is needed by reviewing both the skilled nature of the service and the need for Physician-directed medical management.

Any combination of Network and Out-of-Network Benefits is limited to 120 visits per calendar year. One visit equals four hours of Skilled Home Health Care services.

For Out-of-Network Benefits, please notify the Claims Administrator five business days before receiving services.

Hospice Care

Hospice care is an integrated program recommended by a Physician which provides comfort and support services for the terminally ill. Hospice care can be provided on an inpatient or outpatient basis and includes physical, psychological, social and spiritual care for the terminally ill person, and short-term grief counseling for immediate family members. Benefits are available only when hospice care is received from a licensed hospice agency. For Out-of-Network Benefits, please notify the Claims Administrator five business days before receiving services. The Claims Administrator will advise you of the out-of-pocket costs for home health care visits.

Hospital — Inpatient Stay

The Medical Benefit Program will pay Benefits for an Inpatient Stay at a Hospital for the following:

 Services and supplies received during an Inpatient Stay; and

 Room and board in a semi-private room (a room with two or more beds).

The Medical Benefit Program will pay for a private room only if a private room is necessary according to generally accepted medical practice.

Benefits for an Inpatient Stay in a Hospital are available only when the Inpatient Stay is necessary to prevent, diagnose or treat a Sickness, Injury, Pregnancy, mental illness, or substance abuse disorder. Benefits for Hospital-based Physician services are described in this section under Professional Fees for Surgical and Medical Services.

Professional fees for mental health and substance use disorder benefits are described in the EAP/Managed Behavioral Health Care section of the TEBP SPD.

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Please remember, for out-of-network benefits, you must notify the Claims Administrator as follows:

 For elective admissions: five business days before admission

 For Emergency care that results in an Inpatient admission (also termed non-elective

admissions): within two business days, or as soon as is reasonably possible

 For Out-of-Network Benefits, please notify the Claims Administrator five business days before

receiving services.

Injections in a Physician’s Office

Benefits are paid by the Plan for injections administered in the Physician’s office, for example allergy immunotherapy, when no other health service is received.

What is Co-insurance?

Co-insurance is the amount you pay for a Covered Health Service, not including the co-pay and/or the Deductible.

For example, after satisfying your Deductible, if the Plan pays 80% of Eligible Expenses for care received from a Network Provider, your co-insurance is 20%.

Kidney Dialysis

All Covered Persons receiving Outpatient Dialysis treatment will be subject to the Medical Benefit Program’s case management provisions, negotiations and other Plan services which the Plan Sponsor may elect to apply in the exercise of its discretion. Payment for both Network and Out-of-Network Outpatient Dialysis Treatment will be based on the Outpatient Dialysis Reasonable and Customary Charge, as defined herein. The Plan shall pay no more than the Outpatient Dialysis Reasonable and Customary Charge in connection with Outpatient Dialysis claims, after deduction of all amounts subject to Deductible, Co-insurance, or applicable Co-payments.

Maternity Services

Benefits for Pregnancy will be paid at the levels stated in Medical Benefit Program Options: Highlights for all Dependents covered under the Medical Benefit Program. This includes all maternity-related medical services for prenatal care, postnatal care for the mother, delivery, and any related

complications, except that any service which is required by to be covered at 100% as “preventive care” will be paid at 100% without cost-sharing.

The Plan will pay Benefits for an Inpatient Stay of the following durations:

 48 hours for the mother and newborn child following a vaginal delivery, or

 96 hours for the mother and newborn child following a cesarean section delivery

These are federally mandated requirements under the Newborns’ and Mothers’ Health Protection Act of 1996. If the mother agrees, the attending Physician may discharge the mother and/or the newborn child earlier than these minimum timeframes.

If you are treated out-of network and expect your stay will be longer than the times noted above, please contact your Claims Administrator to ensure the plan pays at the highest coverage level.

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Note: Although your Dependent children enrolled in the Medical Benefit Program will receive Benefits for Maternity Services, a child of your Dependent Child (i.e. your grandchild) is not eligible to be enrolled in the Medical Benefit Program (unless that grandchild is also your adopted child or foster child).

Nutritional Counseling

The Medical Benefit Program will pay for Covered Health Services provided by a registered dietician in an individual session if you have a medical condition that requires a special diet. Some examples of such medical conditions include:

 Diabetes mellitus

 Coronary artery disease

 Congestive heart failure

 Severe obstructive airway disease

 Gout (a form of arthritis)

 Renal failure

 Phenylketonuria (a genetic disorder diagnosed at infancy), and

 Hyperlipidemia (excess of fatty substances in the blood)

Benefits are limited to twelve individual sessions in your lifetime for each medical condition requiring a special diet.

Obesity Surgery

The Plan covers surgical treatment of morbid obesity provided all of the following are true:

 You have a minimum Body Mass Index (BMI) greater than 40 or you have a BMI greater than 35

with one of the following conditions:

o Coronary heart disease

o Type 2 diabetes

o Sleep apnea

o Hypertension, or

o Severe psychiatric disturbance

 You are over the age of 18, and

 The surgery is performed at a Hospital by a surgeon

 You are required to participate in a three month multidisciplinary regimen in preparation for

surgery

 Benefits are limited to a lifetime maximum of two procedures per Covered Person

Outpatient Surgery, Diagnostic and Therapeutic Services

The Medical Benefit Program will pay Benefits (at the levels stated in Medical Benefit Program Options: Highlights) for Outpatient Surgery and Diagnostic and Therapeutic Services, including the following:

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Benefits include only the Facility charge and the charge for required services, supplies and equipment. Benefits for the professional fees, including a surgeon’s fee related to Outpatient Surgery, Diagnostic and Therapeutic Services are described under Professional Fees for Surgical and Medical Services in this section. When these services are performed in a Physician’s office, Benefits are described under Physician’s Office Services as follows.

Physician’s Office Services

The Medical Benefit Program will pay Benefits (at the levels stated in Medical Benefit Program Options: Highlights) for Covered Health Services received in a Physician’s office, including the following:

 Evaluation and treatment of a Sickness, Injury and Pregnancy; and

 Vision and hearing screenings, which could be performed as part of an annual physical examination

in a Provider’s office (vision screenings do not include refractive examinations to detect vision impairment).

Benefits for preventive services are described under Preventive Care in this section.

Preventive Care

The Medical Benefit Program will cover any service considered to be “preventive care” within the meaning of Department of Labor regulation section 2590.715-2713 (or successor regulation) at 100% without cost-sharing, as long as those services are covered by a Network Provider. If services are provided by an Out-of-Network Provider, they will be covered at the levels stated in Medical Benefit Program Options: Highlights. The services considered to be “preventive care” may change over time, and if they do, the coverage of such services under the Medical Benefit Program will also change. For a description of services currently considered to be “preventive care,” see

www.healthcare.gov/law/resources/regulations/prevention/recommendations.html.

Professional Fees for Surgical and Medical Services

The Medical Benefit Program pays professional fees for surgical procedures and other medical care received from a Physician in a Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility, Alternate Facility, outpatient surgery Facility, or birthing center at the levels described in Medical Benefit Program Options: Highlights.

When these services are performed in a Physician’s office, Benefits are described under Physician’s

Office Services in this section. See theEAP/Managed Behavioral Health Caresection of the TEBP SPD

for benefits for professional fees for mental health and substance use abuse disorder.

Prosthetic Devices

Benefits are paid by the Medical Benefit Program at the same levels as Durable Medical Equipment for Prosthetic Devices and appliances that replace a limb or body part, or help an impaired limb or body part work. Examples include, but are not limited to:

 Artificial limbs

 Artificial eyes, and

 Breast prosthesis following mastectomy as required by the Women’s Health and Cancer Rights Act

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If more than one Prosthetic Device can meet your functional needs, Benefits are available only for the most Cost-Effective prosthetic device. The device must be ordered or provided either by a Physician, or under a Physician’s direction.

Benefits are provided for the replacement of a type of Prosthetic Device once every five calendar years.

Note: Prosthetic Devices are different from DM. See“Durable Medical Equipment”(DME) in this section.

Reconstructive Procedures

Reconstructive Procedures are services performed when a physical impairment exists and the primary purpose of the procedure is to improve or restore physiologic function for an organ or body part. Improving or restoring physiologic function means that the organ or body part is made to work better. An example of a Reconstructive Procedure is surgery on the inside of the nose so that a person’s breathing can be improved or restored.

Benefits for Reconstructive Procedures include breast reconstruction following a mastectomy and reconstruction of the non-affected breast to achieve symmetry. Replacement of an existing breast implant is covered by the Medical Benefit Program if the initial breast implant followed mastectomy. There may be times when the primary purpose of a procedure is to make a body part work better. However, in other situations, the purpose of the same procedure is to improve the appearance of a body part. A good example is upper eyelid surgery. At times, this procedure will be done to improve vision, which is considered a Reconstructive Procedure. In other cases, improvement in appearance is the primary intended purpose, which is considered a Cosmetic Procedure. This Plan does not provide Benefits for Cosmetic Procedures, as defined in theGlossary.

Please remember that you must notify the claims administrator five business days before undergoing a Reconstructive Procedure. When you provide notification, the Claims Administrator can determine whether the service is considered reconstructive or cosmetic. Cosmetic Procedures are always excluded from coverage.

Rehabilitation Services — Outpatient Therapy

The Medical Benefit Program provides Benefits (at the coverage levels stated in Medical Benefit Program Options: Highlights) for short-term outpatient Rehabilitation Services for the following types of therapy:

 Physical

 Occupational

 Speech

 Pulmonary rehabilitation, and

 Cardiac rehabilitation

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Speech Therapy for Children

Benefits are paid for services of a licensed speech therapist (at the rates stated in Medical Benefit Program Options: Highlights) for treatment given to a child whose speech is impaired due to one of the following conditions:

 Infantile autism

 Development delay or cerebral palsy

 Hearing impairment, or

 Major Congenital Anomalies that affect speech, such as, but not limited to, cleft lip and cleft palate

The Plan will pay Benefits for Speech Therapy only when the speech impediment or dysfunction results from Injury, Sickness, stroke or a Congenital Anomaly, or is needed following the placement of a cochlear implant.

Any combination of Network and Out-of-Network Benefits are limited to 60 visits per calendar year for physical, occupational and Speech Therapy combined.

Skilled Nursing Facility/Inpatient Rehabilitation Facility Services

Facility services for an Inpatient Stay in a Skilled Nursing Facility or Inpatient Rehabilitation Facility are covered by the Medical Benefit Program at the levels stated in Medical Benefit Program Options: Highlights. Benefits include:

 Services and supplies received during the Inpatient Stay; and

 Room and board in a semi-private room (a room with two or more beds).

Benefits are available when Skilled Nursing and/or Inpatient Rehabilitation Facility services are needed on a daily basis. Benefits are also available in a Skilled Nursing Facility or Inpatient Rehabilitation Facility for treatment of a Sickness, Injury, Pregnancy, mental health or substance use disorder that would have otherwise required an Inpatient Stay in a Hospital.

The intent of skilled nursing is to provide Benefits if, as a result of an Injury, illness, Pregnancy, mental health or substance use disorder, you require:

 An intensity of care less than that provided at a general acute Hospital but greater than that

available in a home setting; or

 A combination of skilled nursing, rehabilitation and Facility services.

You are expected to improve to a predictable level of recovery. Where Hospice Care is required, it is covered under certain conditions and at different coverage levels.

Note: The Plan does not pay Benefits for Custodial Care or Domiciliary Care (as such terms are defined the Glossary), even if ordered by a Physician.

Any combination of Network and Out-of-Network Benefits is limited to 60 days per calendar year. For out- of-network benefits, you must notify the Claims Administrator as follows:

 For elective admissions: five business days before admission;

 For an Inpatient admission following emergency care (also termed non-elective admissions):

within two business days or as soon as is reasonably possible.

If you don’t notify us, your Benefits may be subject to a penalty. (Note: The penalty will not apply if the Inpatient admission constitutes “emergency services” (within the meaning of Department of Labor regulation section 2590.715-2719A(b)(4)(ii) or successor regulation) necessary to stabilize the patient.

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Transplantation Services

Inpatient Facility services (including evaluation for transplant, organ procurement and donor searches) for transplantation procedures must be ordered by a Provider. Benefits are available for any of the organ and tissue transplants listed below when the transplant meets the definition of a

Covered Health Service and is not Experimental and Investigational, or Unproven:

 Heart  Heart/lung  Lung  Kidney  Kidney/pancreas  Liver  Liver/kidney  Liver/intestinal  Pancreas  Intestinal, and

 Bone marrow (either from you or from a compatible donor) and peripheral stem cell transplants,

with or without high dose chemotherapy. Not all bone marrow transplants meet the definition of a Covered Health Service — please see below.

The Plan has specific guidelines regarding Benefits for transplant services. Contact the Claims Administrator by calling member services at the toll-free number on your ID card.

The search for bone marrow/stem cells from a donor who is not biologically related to the patient is a Covered Health Service.

Benefits are also available for cornea transplants that are provided by a Network Provider at a Network Hospital.

If you or a family member needs an organ or bone marrow transplant, the Claims Administrator can put you in touch with quality treatment centers around the country.

Please remember, if transplant services are to be provided Out-of-Network, you must notify the Claims Administrator as soon as the possibility of a transplant arises (and before the time a pre-transplantation evaluation is performed at a transplant center).

Urgent Care Services

The Medical Benefit Program provides Benefits for services, including professional services, received at an Urgent Care Center, as defined in the Glossary. When Urgent Care services are provided in a

Physician’s office, the Plan pays Benefits as described under Physician’s Office Services earlier in this section.

Resources to Help You Stay Healthy

This section describes health and well-being resources available to you including:

 HealthyatTenet.com(see My Wellness Center)

 Healthy Pregnancy Program

Tenet believes in giving you the tools you need to be an educated health care consumer. To that end, Tenet has made available several convenient educational and support services, accessible by phone