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Swedish Health Services Swedish Grandfathered Retiree Plan

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					          Swedish Health Services
Swedish Grandfathered Retiree Plan Document
  Medical (Including Prescription Drug) and
               Dental Benefits
Table of Contents
Important Information About the Swedish Grandfathered Retiree Plan ................................. 1

Contacting First Choice Health Administrators .......................................................................... 2

How to Obtain Health Services ...................................................................................................... 3
      Your ID Card ............................................................................................................................. 3
      Choosing a Provider................................................................................................................... 3

Eligibility .......................................................................................................................................... 4
      Eligible Classes of Retirees........................................................................................................ 4
      Medicare Eligible....................................................................................................................... 4
      Medicare COB ........................................................................................................................... 4

Dependents....................................................................................................................................... 5
      Dependent Eligibility ................................................................................................................. 5
      Dependents Acquired Through Marriage .................................................................................. 5
      Dependent Children ................................................................................................................... 6
      Continued Eligibility for a Disabled Child ................................................................................ 7
      Qualified Medical Child Support Orders ................................................................................... 7

Medical Management...................................................................................................................... 9
      Notification Requirements ......................................................................................................... 9

Medical Benefit Maximums and Limitations ............................................................................... 10
      Basic Medical Benefits/Supplemental Accident Benefit ........................................................... 10
      Major Medical Benefits ............................................................................................................. 10
      Lifetime Maximums................................................................................................................... 11
      Annual Deductible ..................................................................................................................... 11
      Annual Out-of-Pocket Maximum .............................................................................................. 11
      Calendar Year Maximum........................................................................................................... 12
      Participant Reimbursement Liability ......................................................................................... 12

Schedule of Medical Benefits.......................................................................................................... 13

Benefits Classified as Optional: Paid at 100% With No Deductible .......................................... 16
      Breast Augmentation or Breast Reduction................................................................................. 16
      Dental Trauma............................................................................................................................ 16
      Fertility Testing.......................................................................................................................... 16
      Foot Disorders............................................................................................................................ 17
      Intentionally Self-inflicted Injury .............................................................................................. 17
      Maternity (for retirees and spouses only) .................................................................................. 17
      Orthotics, Orthopedic, Corrective Shoes or Other Supportive Appliances ............................... 18
      Pediatric and Newborn Care ...................................................................................................... 18
      Temporomandibular Joint (TMJ) Disorder................................................................................ 18

Covered Medical Services and Supplies........................................................................................ 19
      Alcohol and Drug Abuse Rehabilitation (Chemical Dependency)............................................ 19
      Ambulance ................................................................................................................................. 20
      Durable Medical Equipment (DME), Medical Supplies and Prosthetic Devices ...................... 20
      Emergency and Urgent Care ...................................................................................................... 22
      Home Health Care...................................................................................................................... 22
      Hospice Care .............................................................................................................................. 23
      Hospital Inpatient....................................................................................................................... 24
      Hospital Outpatient .................................................................................................................... 24
      Lab and Radiology Services ...................................................................................................... 24
      Mental Health Care .................................................................................................................... 24
      Organ and Bone Marrow Transplants........................................................................................ 25
      Plastic and Reconstructive Services........................................................................................... 27
      Prescription Drugs...................................................................................................................... 28
      Surgeon and Professional Services ............................................................................................ 28
      Rehabilitation Therapy............................................................................................................... 28
      Skilled Nursing Facility (Combined With Inpatient Rehabilitation) ......................................... 29
      Women’s Health and Cancer Rights Act of 1998 Disclosure.................................................... 30

Medical Limitations and Exclusions.............................................................................................. 31

Covered Dental Services and Supplies .......................................................................................... 36
      Annual Dental Deductible.......................................................................................................... 36
      Dental Expenses......................................................................................................................... 36
      Class I Benefits – Preventive and Diagnostic Care.................................................................... 37
      Class II Benefits – Basic Restorative Care ................................................................................ 38
      Class III Benefits – Major Restorative Care .............................................................................. 39

Dental Limitations and Exclusions ................................................................................................ 40

Termination of Coverage................................................................................................................ 43
      Effect of Employer Chapter 11 Proceedings on Retiree Coverage............................................ 44

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)....................................... 45
      Who Is a COBRA Qualified Beneficiary?................................................................................. 45
      Qualifying Events and Continuation Periods............................................................................. 46
      When COBRA Coverage Ends .................................................................................................. 46
      Contribution Payment Requirements ......................................................................................... 46
      Election Requirements ............................................................................................................... 47
      What Coverage Must Be Offered When Electing COBRA? ..................................................... 47
      Group Health Plan Qualified Status Changes ............................................................................ 47

Coordination of Benefits................................................................................................................. 48
      Benefits Subject to the COB Provision...................................................................................... 48
      Determination of Plan Priority................................................................................................... 48
      Meaning of Plan for COB .......................................................................................................... 49
      Claim Determination Period ...................................................................................................... 50
      Right of Recovery ...................................................................................................................... 50
      Facility of Payment .................................................................................................................... 50
      Right to Receive and Release Information ................................................................................ 50

Subrogation...................................................................................................................................... 51
      Liable Third Parties and Insurers ............................................................................................... 51
      Uninsured/Underinsured Motorist Coverage ............................................................................. 52
      Venue ......................................................................................................................................... 52
      Subrogation Forms..................................................................................................................... 52

Health Insurance Portability and Accountability Act of 1996.................................................... 53
      Privacy Rights ............................................................................................................................ 53

Plan Benefit Information ................................................................................................................ 54
      Benefits and Contributions......................................................................................................... 54
      Benefits Under Qualified Medical Child Support Orders.......................................................... 54
      Benefits for Adopted Children................................................................................................... 54
      Special Rights – Childbirth Hospitalization............................................................................... 54

Claim and Appeal Procedures ....................................................................................................... 55
      How to File a Claim for Plan Benefits....................................................................................... 55
      Claim Types ............................................................................................................................... 55
      Claim Procedure......................................................................................................................... 56
      Appeal Procedure....................................................................................................................... 57

Plan Administration........................................................................................................................ 60
      Funding ...................................................................................................................................... 60
      Plan Administrator’s Power of Authority .................................................................................. 60
      Discretionary Authority ............................................................................................................. 60
      Collective Bargaining Agreements ............................................................................................ 60
      Clerical Error.............................................................................................................................. 61
      Waiver of Group Health Plan Benefits ...................................................................................... 61

Statement of ERISA Rights............................................................................................................ 62
      Prudent Actions by Plan Fiduciaries.......................................................................................... 62
      Enforce Your Rights .................................................................................................................. 62
      Continue Group Health Coverage.............................................................................................. 63
      Assistance With Your Questions ............................................................................................... 63

Summary Plan Description and General Information ................................................................ 64

Plan Definitions ............................................................................................................................... 66
Important Information About the Swedish
Grandfathered Retiree Plan
This booklet describes your coverage and payment levels under the Swedish Grandfathered Retiree Plan
as of January 1, 2004 and how to use your benefits as well as information about claims, eligibility,
enrollment, coordination of benefits, subrogation and other plan provisions.

Swedish Health Services, the employer and Plan Sponsor of this self-funded Plan, contracts with First
Choice Health Administrators (FCHA – a division of First Choice Health Network, Inc.) as TPA (Third
Party Administrator) to perform certain Plan services.

Under the Swedish Grandfathered Retiree Plan, you are protected against certain catastrophic health
expenses.

Please review this booklet carefully and share it with your family. If you have questions, contact the
Swedish Health Services Benefits Department or FCHA.




Coverage under this Plan will take effect for eligible retirees and dependents when all eligibility requirements are satisfied.
Swedish Health Services fully intends to maintain this Plan indefinitely, but reserves the right to terminate, suspend, discontinue
or amend the Plan at any time, for any reason.

The Plan will pay benefits only for expenses incurred while this coverage is in force. No benefits are payable for expenses
incurred before coverage began or after it terminated, even if the expenses result from an accident, injury or disease that
occurred, began or existed while coverage was in force. An expense for a service or supply is incurred on the date the service or
supply is furnished. If the Plan terminates, the rights of participants and beneficiaries are limited to charges incurred before
termination.

This Swedish Grandfathered Retiree Plan booklet is the Plan document and summary plan description.




                                                                 1
Contacting First Choice Health Administrators
You may call FCHA Customer Service directly whenever you have questions or concerns at the number
printed on your ID card or contact FCHA by mail, fax or Internet:

    First Choice Health Administrators
    Customer Service Department
    PO Box 12659
    Seattle WA 98111-4659
    800-750-5202
    Local: 206-268-2360
    Fax: 888-206-3092
    Medical pre-certification: 800-808-0450
    Mental health/chemical dependency pre-certification: 800-640-7682
    www.1stchoiceadmin.com

FCHA business hours to speak to a Customer Service Representative are Monday through Friday,
8:00 AM to 5:00 PM (Pacific Standard Time). The office is closed on New Year’s Day, Martin Luther
King Day, Memorial Day, Independence Day (4th of July), Labor Day, Thanksgiving, the day after
Thanksgiving, Christmas Eve and Christmas Day. FCHA offices close at 3:00 PM on the day before
Thanksgiving and on December 23. If the holiday falls on a Saturday, the office is closed on Friday; if the
holiday falls on Sunday, the office is closed Monday (the holiday is recognized during the same calendar
week in which the holiday falls).

You can access benefit information or your specific claim and enrollment status anytime at
www.1stchoiceadmin.com or by calling FCHA Customer Service’s automated voice response system at
800-750-5202.




                                                     2
How to Obtain Health Services
Your ID Card
Your ID card identifies you as a Swedish Health Services plan participant and contains important
information about your coverage and benefits. We recommend presenting your ID card each time you
receive care. If you lose your ID card, notify FCHA Customer Service immediately and a representative
will assist you in obtaining a new card. Under no circumstances should you give your ID card to another
person for their use.


Choosing a Provider
First Choice Health Network (FCHN) is the provider network for this Swedish Health Services plan.
Although you’re not required to see a network provider, the advantage of FCHN preferred provider
network arrangements may reduce your coinsurance costs when you do choose a network provider.

The Providence Preferred Network of Oregon is the network for participants who live or work in Oregon
and for dependents with active student status in Oregon. The Providence Preferred Network of Oregon is
also available to all participants for urgent or emergency care when traveling in Oregon.

The Beech Street Network is the network for participants who live or work outside of the FCHN or
Providence Preferred Network of Oregon service areas and for dependents with active student status
outside of the FCHN and Providence Preferred Network of Oregon service areas. The Beech Street
Network is also available to all participants for urgent or emergency care when traveling.

Contact the networks for provider lists and other information:

       Networks                   State/Area                  Phone                 Websites
 First Choice            Washington, Alaska,              800-430-3818    www.1stchoiceadmin.com
 Health Network          Montana, Idaho
 Providence Preferred    Oregon – Portland metro area     800-430-3818    www.providence.org/oregon
 Network of Oregon       and parts of Western Oregon



 Beech Street            All other states/areas not       800-877-1444,   www.beechstreet.com
 Network                 served by FCHN or                ext.2
                         Providence Preferred
                         Network of Oregon




                                                      3
Eligibility
Eligible Classes of Retirees
An eligible participant is the former employee of Providence Health Systems, now known as Swedish
Health Services, who retired from the employ of Providence Health Systems between May 1, 1979 and
June 1, 1985.

You will not be denied enrollment due to your health status.


Medicare Eligible
For enrolled retirees and dependents who are eligible for Medicare, including a retiree’s former dependent
spouse or a retiree or retiree’s dependent who is eligible for Medicare due to end stage renal disease after
that person has been eligible for Medicare for 30 months, the Plan will be modified (where permitted by
the rules of the Social Security Act of 1965 as amended) as follows:

•   The amount payable under this Plan will be reduced so that the total amount payable by Medicare and
    by the Plan will be no more than 100% of the expenses incurred

•   A person is considered eligible for Medicare on the earliest date any coverage under Medicare could
    become effective for them.


Medicare COB
If the enrolled participant is a Medicare beneficiary, this Plan will be considered secondary to Medicare.




                                                     4
Dependents
Dependent Eligibility
Dependents become eligible for group health plan benefits on the day you acquire your first dependent.
Dependents include your:

•   Lawful spouse

•   Unmarried natural child, adopted child, child placed with you for legal adoption, stepchild or other
    legally designated ward up to age 19 (the limiting dependent child age) or up to age 23 if an actively
    enrolled full-time student

•   Unmarried natural child, adopted child, a child placed with you for legal adoption, stepchild or other
    legally designated ward that a health care professional determines is not capable of self-sustaining
    employment due to a physical or mental handicap.

The newborn child of an enrolled dependent child is not eligible for coverage.

A child who loses dependent status for coverage eligibility under this provision may be eligible for
continuation of coverage under COBRA. (See COBRA section and contact the Swedish Health Services
Benefits Department (the Plan Administrator) for eligibility requirements.)

As a retiree participant, you’re responsible for paying the contribution for your dependent’s group health
plan benefits.

Your dependents will be enrolled in this group health plan only if you’re enrolled.


Dependents Acquired Through Marriage
If you acquire a new dependent through marriage, the Plan Administrator must receive the completed
enrollment application and a copy of the marriage certificate within 31 days after the marriage for
coverage to be effective.

Coverage for dependents from a lawful marriage becomes effective on the first of the month following the
marriage. If the completed enrollment application isn’t received within 31 days of marriage, the
dependent will not be able to enroll until the next open enrollment.




                                                     5
Dependent Children
An enrollment form is required to enroll any dependent child. Your dependent will not be denied based on
health status. The Plan Administrator (Benefits Department) may ask for added information to establish a
dependent child’s eligibility.

Children of married Swedish Health Services plan participants may enroll under only 1 parent.

Natural Newborn Children
If you acquire a new dependent through birth, the Benefits Department must receive the enrollment form
within 60 days of the birth to avoid claim delay. Submit the enrollment form for the newborn as soon as
possible. Coverage for natural newborns becomes effective on the date of birth.

Adopted Children
If you acquire a new dependent through adoption or placement for adoption you may enroll your eligible
dependents and yourself, if you’re not already enrolled, within 60 days of such event.

Adopted Children Acquired
Any child under age 18 you legally adopt or who’s placed with you for adoption is eligible on the date of
placement. A child is considered placed for adoption when you become legally obligated to support that
child totally or partially before the legal adoption. If the child is placed but not adopted, all group health
plan benefits stop when the placement ends and will not be continued.

If the enrollment form, with documentation to support legal guardianship, is received within 60 days of
placement, coverage becomes effective on the date of placement. The Plan Administrator may request
added information.

Children Acquired Through Legal Guardianship
If the enrollment form, with documentation to support legal guardianship, is received within 60 days of
obtaining legal guardianship, dependent coverage becomes effective on the date of the order. The Plan
Administrator may request added information.

Children Covered Under Medical Child Support Orders
If the enrollment form, with notification of the medical child support order (from you, the custodial parent
or a state agency administering Medicaid) is received within 31 days of the order, coverage becomes
effective on the date of the order. If received after 31 days, coverage becomes effective on the first of the
month after the Plan Administrator has the enrollment information. (See below for more information on
medical child support orders.)




                                                      6
Continued Eligibility for a Disabled Child
Coverage may be extended beyond the dependent child limiting age if the child is:

•   Incapable of self-sustaining employment due to developmental disability or physical handicap, and

•   Depends primarily on you for support.

Contact the Benefits Department for details and enrollment forms. For continued eligibility of a disabled
child, the enrollment form must be received 31 days after the child’s 19th birthday.


Qualified Medical Child Support Orders
Swedish Health Services will provide medical and dental coverage to certain children (called alternate
recipients) if directed by a Qualified Medical Child Support Order (QMCSO). A medical child support
order:

•   Is any decree, judgment, order (including approval of settlement agreement) or administrative notice
    from a state court or state agency with jurisdiction over the child’s support

•   Recognizes the child as an alternate recipient for plan benefits

•   Provides for, based on a state domestic relations law (including a community property law), the
    child’s support or health plan coverage.

A QMCSO is a medical child support order qualified under the Omnibus Budget Reconciliation Act of
1993. A medical child support order is qualified if it creates or recognizes the existence of an alternate
recipient’s right to receive plan benefits and specifies this information:

•   Retiree’s name and last known address

•   Each alternate recipient’s name and address (or state official/agency name and address if the order
    provides)

•   Reasonable description of coverage the alternate recipient is entitled to receive

•   Coverage effective date

•   How long the child is entitled to coverage

•   That the plan is subject to the order.

If the medical child support order is a QMCSO:

•   The Plan Administrator notifies you and the alternate recipient of the Plan’s procedures and allows
    the alternate recipient to name a representative to receive copies of any QMCSO notices

•   Alternate recipient coverage begins on the first of the month after the QMCSO is received




                                                      7
•   If a dependent contribution is required, your specific authorization isn’t needed to establish the
    payroll deduction, which would be retroactive to the alternate recipient’s coverage effective date

•   The Plan pays network providers directly for covered services; when an alternate recipient, custodial
    parent, legal guardian or retiree pays a covered expense, the Plan reimburses the person who paid the
    expense.

If the medical child support order isn’t a QMCSO, the Plan Administrator notifies you and each alternate
recipient of the specific reasons it doesn’t qualify, along with procedures for submitting a corrected
medical child support order.




                                                     8
Medical Management
Notification Requirements
There is no pre-certification requirement for the Swedish Grandfathered Retiree Plan. However, you may
call FCHA Customer Services (800-750-5202) if you have questions regarding preferred facilities or
FCHA Medical Management (800-808-0450) to answer coordination of care questions.

Your provider may submit a request to the FCHA Medical Management department prior to any service
for benefit or medical necessity determinations. If a service may be considered experimental or
investigational for a given condition, we recommend a benefit determination in advance. Experimental or
investigational services (see Plan Definitions) are not eligible for coverage.




                                                   9
Medical Benefit Maximums and Limitations
This Plan contains components of basic medical benefits with a supplemental accident benefit and a
major medical benefit.


Basic Medical Benefits/Supplemental Accident Benefit
If benefits paid as a result of an accidental injury do not cover expenses in full, up to $600 in additional
benefits will be provided for each injury. Treatment must begin within 30 days of the accident and all
services must be received within 12 months of the date of injury. The covered person must be
continuously covered by this Plan from the date of the injury. Benefits include:

•   Services of a participating physician; services of a dentist for repair of injury to sound, natural teeth;
    injuries caused by biting or chewing are not covered

•   Charges of a hospital or skilled nursing facility: room, board, and general nursing care, limited to the
    facility or hospital’s average semiprivate room rate

•   Necessary durable medical equipment and the following special items: casts, splints, braces,
    prostheses, surgical and orthopedic appliances, surgical dressings and oxygen

•   Drugs requiring a prescription by federal or state law

•   Transportation by a licensed ambulance company when medically necessary, if other means of travel
    would endanger health and the purpose of the transportation is not for personal or convenience
    reasons.


Major Medical Benefits
The major medical portion of this Plan will cover expenses in excess of the $100 per person deductible
each calendar year. When all members of a family have satisfied $300 of deductible charges, no further
deductible will apply for the remainder of that calendar year.

Covered expenses accumulated and applied to the deductible during the last 3 months of a calendar year
may also be applied to the subsequent year’s deductible.

If 2 or more covered family members are injured in the same accident, they need incur only 1 deductible
for any treatment received in that and the next calendar year as a result of the accident.

If a hospitalization continues into the next calendar year, a second deductible will not be required for any
treatment prior to discharge from the hospital.

Major medical benefits of this Plan are limited to a $1,000,000 lifetime maximum for each covered
person. In addition:

•   Up to $20,000 of benefits paid will be reinstated automatically January 1 of each year




                                                      10
•   The benefits of this Plan are provided only for medically necessary covered services at the
    percentages specified below after the applicable deductible has been met

•   When the annual out-of-pocket maximum has been reached, the Plan will provide benefits for many
    covered services at 100% of the allowed amount for the remainder of the calendar year. Exceptions
    are noted in the Annual Out-of-Pocket Maximum section below.


Lifetime Maximums
The lifetime maximum benefit is the total amount of Swedish Grandfathered Retiree Plan group health
benefit coverage you may receive for the span of your life as long as you’re enrolled in this Plan.

                                       Lifetime Maximum Benefit
Individual Aggregate                                       $1,000,000
                                                           Automatic annual restoration $20,000 on
                                                           January 1 each year
Hospice (counseling and bereavement not included)          $10,000
Alcoholism Treatment (inpatient and outpatient)            Inpatient: $4,800
                                                           Outpatient: $2,400
Drug Abuse and Chemical Dependency Treatment               Inpatient: $7,200
(inpatient and outpatient)                                 Outpatient: $1,500



Annual Deductible
The annual deductible is the amount you (or your family) must pay each calendar year before the Plan
pays for covered services. Only certain covered services apply toward the annual deductible. The amount
due a provider is your responsibility until the annual deductible has been satisfied.

                                           Annual Deductible
Individual       $100
Family           $300 (only 2 times the individual deductible for a 2-member family)
Carryover        • If a hospitalization continues into the next calendar year, a second deductible will not
                   be required for any treatment prior to discharge from the hospital
                 • 3-month carryover for all other benefits



Annual Out-of-Pocket Maximum
When the annual out-of-pocket maximum has been reached, the Plan will provide benefits for many
covered services at 100% of the allowed amount for the remainder of the calendar year. Exceptions are
noted below.

                                   Annual Out-of-Pocket Maximum
Individual                                        $1,500




                                                           11
The following do not count toward the annual out-of-pocket maximum; coinsurance amounts for the
specified benefits do not change if the annual out-of-pocket maximum is reached:

•   The annual deductible

•   Coinsurance for mental health services, alcohol and drug abuse rehabilitation

•   Costs of non-covered or non-prescribed treatment

•   Costs for treatment beyond a benefit maximum

•   Costs over usual, customary and reasonable (UCR – see Plan Definitions in this booklet) for non-
    network providers as determined by FCHA

•   Durable medical equipment and prosthetic devices.


Calendar Year Maximum
Calendar year maximum means the amount of maximum medical benefit available to a participant each
calendar year.

                                       Calendar Year Maximums
Home Health Care                                     $10,000
Inpatient Mental Illness                             10 days
Outpatient Mental Illness                            15 visits
Rehabilitation therapy (includes speech,             12 months from onset/condition, all therapies
occupational and physical)                           combined
Alcohol Abuse Treatment (inpatient and outpatient)   Inpatient: $3,200
                                                     Outpatient: $1,600
Drugs and Chemical Dependency Treatment              Inpatient: $3,800
(inpatient and outpatient)                           Outpatient: $1,000



Participant Reimbursement Liability
You are always responsible for the following costs associated with your health care:

•   Annual deductible, if applicable

•   Coinsurance, if applicable

•   The difference between a non-network provider’s charge for a service and FCHA’s allowed amount
    for that service (see UCR in Plan Definitions)

•   Any costs for care you receive after your benefit limits have been exhausted

•   Any costs for non-covered services.




                                                      12
Schedule of Medical Benefits
                                 Swedish Grandfathered Retiree Plan

Benefit                                           Basic Medical Benefits      Major Medical Benefits
Alcoholism Treatment                             Course of treatment must be completed before benefit
                                                 is paid
• Inpatient
  Calendar year maximum $3,200                                               80% after deductible
  Lifetime maximum $4,800
• Outpatient
  Calendar year maximum $1,600                                               80% after deductible
  Lifetime maximum $2,400
Ambulance                                        First $100 paid at 100%
                                                 with no deductible/
                                                 condition; remainder of     80% after deductible
                                                 charges paid under major
                                                 medical
Anesthesiologist                                 100%
                                                 No deductible
Blood, Blood Plasma, Testing and Storage of
                                                                             80% after deductible
Blood for Future Use
Drug Abuse and Chemical Dependency               Course of treatment must be completed before benefit
Treatment                                        is paid
• Inpatient
  Calendar year maximum $3,800                                               80% after deductible
  Lifetime maximum $7,200
• Outpatient
  Calendar year maximum $1,000                                               50% after deductible
  Lifetime maximum $1,500
Diagnostic Lab and Radiology                     In a calendar year, first
                                                 $100 paid at 100%;
                                                                             80% after deductible
                                                 remainder of charges paid
                                                 under major medical
Durable Medical Equipment (DME), Medical
                                                                             80% after deductible
Supplies and Prosthetic Devices
Home Health Care                                 100%
Calendar year maximum $10,000
                                                 No deductible
Hospice
Lifetime maximum $10,000                         100%
Excludes counseling and bereavement              No deductible




                                                   13
                                     Swedish Grandfathered Retiree Plan

Benefit                                               Basic Medical Benefits       Major Medical Benefits
Hospital Inpatient                                   100%
                                                     No deductible
Hospital Outpatient                                  100%
                                                     No deductible
Medical Emergency                                    100%
                                                     No deductible
Mental Health
• Inpatient                                          100%
  10 days/calendar year                              No deductible

• Outpatient
                                                                                  50% after deductible
  15 visits/calendar year
Organ Transplants
                                                     100%
Excludes organ selection, transportation and
storage; includes donor expenses from the date of    No deductible
surgery continuing for 10 days
Pre-admission Testing                                100% (within 48 hours of
                                                     admission)
                                                     No deductible
Prescription Drugs                                                                80% after deductible;
                                                                                  larger of 34-day supply or
Includes antigens, allergies and insulin                                          100 units
Radiation and Chemotherapy                           100%
                                                     No deductible
Rehabilitation                                       100%
Excludes recreational or educational therapy,        No deductible
learning disabilities or chemical and substance
abuse rehab, which is a separate benefit; includes   Up to 12 months from
physical, speech and occupational therapy            onset of injury or illness

Skilled Nursing Facility Room and Board              100%
                                                     No deductible
Surgeon and Physician fees                           100%
Includes but is not limited to lab and radiology,    No deductible
second opinion, injectable drugs




                                                        14
                                    Swedish Grandfathered Retiree Plan

Benefit                                                Basic Medical Benefits       Major Medical Benefits
Special medical items and supplies
(if not covered by any other benefit; remember,
like others, all must be medically necessary to be
covered)
Includes casts, splints and braces (not dental);                                   80% after deductible
surgical and orthopedic appliances (not orthotics);
colostomy bags and related supplies; catheters;
syringes and needles for insulin and allergy
injections; dressings for wounds, cancer, burns or
ulcers; oxygen; and blood bank charges
Supplemental Accident Insurance                       Up to $600/accident;
                                                      treatment must begin
Paid after other basic medical benefits are paid      within 30 days of accident
                                                      and be received within
                                                      12 months of the date of
                                                      injury




                                                        15
Benefits Classified as Optional: Paid at 100%
With No Deductible
Breast Augmentation or Breast Reduction
Medically necessary reconstructive breast surgery will also include surgery performed on the non-
diseased breast.


Dental Trauma
The benefit includes accidental injury to sound natural teeth, tumors and all hospital confinements.

Benefit coverage is provided under this medical plan for the repair, but not the replacement, of a sound
natural tooth that becomes damaged as a result of a non-work related traumatic injury. After the initial
exam by your dentist, you must notify FCHA. All services related to the repair must be completed within
6 months of the date of injury. Any services received after 6 months have elapsed, or after you no longer
participate in this group plan regardless of whether 6 months have elapsed or not, are not covered.
Damage due to biting or chewing is not covered.

For the purposes of this coverage, a “sound natural tooth”:

•   Is free of active or chronic clinical decay

•   Contains at least 50% bony structure

•   Is functional in the arch

•   Has not been excessively weakened by multiple dental procedures.


Fertility Testing
(Excludes the treatment of infertility, artificial insemination, in-vitro fertilization or similar procedures.)

Only the following diagnostic services are covered for the initial diagnosis of infertility and apply to the
retiree and spouse only:

•   Endometrial biopsy

•   Reproductive screening services

•   Hysterosalpingography

•   Sperm count.

The ongoing treatment of infertility is not a covered benefit.



                                                       16
Foot Disorders
Includes office visits with a podiatrist, open cutting procedures for treatment of metatarsalgia or bunions
and associated fees for surgery center, anesthesiologist, lab/x-ray and removal of nail roots.

No coverage is provided for routine foot care for corns, calluses or toenails or for the treatment of weak,
strained, flat, unstable or unbalanced feet.


Intentionally Self-inflicted Injury
Benefits for an injury intentionally self-inflicted are covered in full when resulting from a medical
condition.


Maternity (for retirees and spouses only)
Medical services including prenatal and postnatal treatment of pregnancy (including false labor) and
normal or cesarean delivery covered the same as any other illness or injury for the female participant or
male participant’s wife for services received while she is covered under this Plan. Benefits include:

•   Licensed birthing center delivery and midwives

•   Hospital nursery care for newborns if indicated

•   Pediatric care.

Procedure to diagnose or treat the condition of a fetus prior to birth is limited to:

•   Amniocentesis and/or chromosomal analysis

•   Fetal monitoring

•   Pregnancy-related ultrasound.

The Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA) states that group health plans may
not restrict benefits for any hospital stay in connection with childbirth for the mother or newborn
following a vaginal delivery to less than 48 hours or following a cesarean section to less than 96 hours.
In all cases, the attending provider, in consultation with the mother, will make the decision regarding
length of stay based upon accepted standard medical practice.

Coverage for pregnancy and childbirth in a hospital or birthing center is provided on the same basis as
any other medical condition. Medically necessary prenatal diagnosis of congenital disorders of the fetus
by means of screening and diagnostic procedures during pregnancy is covered. The services of a licensed
physician (MD or DO), an advanced registered nurse practitioner (ARNP), a licensed midwife or a
certified nurse midwife (CNM) are covered under this benefit.

Coverage for complications of pregnancy includes but may not be limited to an extrauterine pregnancy,
cesarean section, miscarriage (other than elective termination), or sickness resulting from pregnancy.




                                                      17
Orthotics, Orthopedic, Corrective Shoes or Other Supportive Appliances
Benefits for the feet are covered when prescribed by a physician including related office visits, diagnostic
and lab services, castings, molds, fittings, necessary adjustment or replacement when:

•   The device is rigid or semi-rigid and corrects a diagnosed musculoskeletal malalignment of a
    weakened or diseased body part

•   The semi-rigid device stops or limits motion of a weak or diseased body part.


Pediatric and Newborn Care
Coverage for a newborn child is provided from the date of birth when the newborn enrolled as a
dependent under this group health plan. Benefits for newborns are subject to deductible and coinsurance
requirements.

If the mother is discharged and the baby remains in the hospital, or if the baby is transferred to another
hospital or readmitted, deductibles would apply to the baby.


Temporomandibular Joint (TMJ) Disorder
Non-surgical services are covered specifically for TMJ treatment; non-surgical services must be:

•   Medically necessary for the treatment of TMJ

•   Effective for the control or elimination of one or more of the following conditions caused by TMJ:
    pain, infection, disease, difficulty in speaking, or difficulty in chewing or swallowing food

•   Not experimental or investigational (see Plan Definitions) as determined by FCHA

•   Not primarily for cosmetic purposes.




                                                     18
Covered Medical Services and Supplies
FCHA administers the benefits described in this section for Swedish Grandfathered Retiree Plan
participants. All benefits are subject to plan exclusions and limits. All coinsurance and deductibles apply.
See Medical Benefit Maximums and Limitations, Schedule of Medical Benefits, Covered Medical
Services and Supplies, Medical Limitations and Exclusions, Plan Definitions and other sections in this
booklet for more details.

Coverage is provided only when all these conditions are met:

•   The service or supply is a listed covered benefit that’s not excluded

•   Specific benefit limits or lifetime maximums are not exhausted

•   All benefit requirements are met

•   The participant is eligible for coverage and enrolled in this plan at the time the service or supply is
    received

•   The service or supply is considered medically necessary for a covered medical condition, as defined.


Alcohol and Drug Abuse Rehabilitation (Chemical Dependency)
Medically necessary services for the treatment of individuals who are addicted to chemical substances,
such as alcohol or DEA-controlled oral, intravenous or inhaled medications and materials. Chemical
dependency networks are often used to provide services. Care management and benefit management is
generally coordinated through a specialized care manager. Please call FCHA at 800-640-7682 for
assistance. The course of treatment must be completed before payment is made.

Coverage for chemical dependency treatment may include:

•   Medically necessary services and supplies for both inpatient and outpatient care

•   Detoxification, supportive services and approved prescription drugs as prescribed.

This benefit does not include:

•   Alcoholics Anonymous or other similar chemical dependency programs or support groups

•   Court-ordered assessments or other assessments to determine the medical necessity of court-ordered
    treatments

•   Court-ordered treatments and treatments related to the deferral or prosecution, deferral of sentencing
    or suspended sentencing or treatments ordered as a condition of retaining motor vehicle driving
    rights, when no medical necessity exists

•   Emergency patrol services




                                                      19
•   Information and referral services

•   Information schools

•   Long-term or custodial care

•   Chemical dependency benefits not specifically listed.


Ambulance
The use of licensed ground or air ambulance transportation services are covered in an emergency to the
nearest hospital where emergency health services can be rendered if the following conditions apply:

•   Use of other forms of transportation would likely endanger the participant’s health

•   Ambulance is not for personal or convenience reasons

•   An inter-facility transfer is medically necessary.


Durable Medical Equipment (DME), Medical Supplies and
Prosthetic Devices
DME is medical equipment that can withstand repeated use, is not disposable, is used to serve a medically
therapeutic purpose, is generally not useful to a person in the absence of a sickness or injury and is
appropriate for use in the home. Benefits will be provided for DME purchase or rental (not to exceed the
purchase price) when prescribed by a physician for therapeutic use in direct treatment of a covered illness
or injury. Repair of covered equipment due to normal use, change in physical condition or growth of a
child is eligible for coverage. Duplicate items are not covered. Purchase (vs. rental) is at the discretion of
FCHA.

Examples of DME are:

•   Walkers

•   Crutches

•   Standard manual wheelchairs

•   Standard manual hospital beds

•   Oxygen and equipment for administering oxygen.

Medical Supplies
Medical supplies are covered for the treatment or care of an appropriate covered condition.




                                                     20
Prosthetic Devices
Prosthetic devices are covered to treat an appropriate covered condition. Standard artificial limbs and eyes
for the replacement of body parts lost as a result of an illness or injury are covered.

Coverage is limited to the purchase and subsequent repair and/or replacement costs necessitated by
physical growth or normal use. Replacement for lost and duplicate items is not covered. In addition to
limitations and exclusions listed elsewhere, there is no coverage for items primarily for use during or to
enable sports and/or recreational activities.

Diabetic DME and Supplies
Coverage for diabetic equipment includes diabetic monitoring equipment and the initial cost of an insulin
pump. Repair of covered equipment due to normal use is eligible for coverage. Foot care appliances for
prevention of complications associated with diabetes are covered. (As with all services and supplies, these
must be medically necessary to be covered.)

Coverage for diabetic supplies is limited to insulin, syringes and needles for diabetic injections, lancets,
urine and blood glucose testing reagents (including visual strips). This benefit is only available under the
prescription drug benefit.

                                                * * * * *

In addition to limitations and exclusions listed elsewhere in this Plan document, this benefit does not
cover:

•   Biofeedback equipment

•   Computer-controlled or microprocessor-controlled prosthetic devices

•   Electronic or keyboard communication devices

•   Exercise equipment or weights

•   Equipment or supplies whose primary purpose is preventing illness or injury

•   Items not manufactured exclusively for the direct therapeutic treatment of an ill or injured patient

•   Items that can be or are available over the counter, except for medically necessary crutches, walkers,
    standard wheelchairs, diabetic supplies and ostomy supplies

•   Items primarily designed to assist a person caring for the patient

•   Items primarily for comfort, convenience, recreational purposes or use outside the participant or
    dependent’s residence

•   Items primarily for use during or to enable sports and/or recreational activities




                                                     21
•   Medical equipment/supplies including regular or special car seats or strollers, push chairs, air
    filtration systems or supplies, orthopedic or other special chairs, pillows, prone standers, adjustable
    beds, bed wetting training equipment, corrective shoes, whirlpool baths, vaporizers, room
    humidifiers, hot tubs or other types of tubs, home UV or other light units, home blood testing
    equipment and supplies (except diabetic DME and supplies are covered) or humidifiers

•   Oral appliances, except for the medically necessary treatment of TMJ

•   Personal comfort items including, but not limited to, air conditioners, lumbar rolls, heating pads,
    diapers or personal hygiene items

•   Supportive equipment/environmental adaptive items including, but not limited to, hand rails, chair
    lifts, ramps, shower chairs, commodes, car lifts, elevators, car or home modifications

•   Wigs or other hair coverings.


Emergency and Urgent Care
Coverage for emergency conditions includes medically necessary emergency room and urgent care visits
in network and non-network facilities.

Emergency (see Plan Definitions) examples include severe pain, difficulty breathing, deep cuts or severe
bleeding, poisoning, drug overdose, broken bones, unconsciousness, stab or gun shot wounds, automobile
accidents and pain or bleeding during pregnancy. Urgent care (see Plan Definitions) examples include
cuts and lacerations, diarrhea, fever, minor allergic reactions, sinus infections, sprains, strains, urinary
tract infections and vomiting.

In the case of an emergency, whether at home or away from home, seek the most immediate care
available.


Home Health Care
Home health care is covered, if prescribed by your physician, when the patient must be homebound and
when the care provided is medically necessary skilled care services. (Skilled care services are those that
must be delivered or supervised by licensed professional medical personnel to obtain the specified
medical outcome.) Benefits are limited to intermittent visits by a licensed home health care agency and
include home infusion services. Any charges for home health care that qualify under this benefit and
under any other benefit of this Swedish Grandfathered Retiree Plan will be covered under the most
appropriate benefit, as determined by FCHA.

A visit is defined as 1 time-limited session or encounter with any of the following home health agency
providers of care:

•   Nursing services (Registered Nurse (RN), Licensed Practical Nurse (LPN))

•   Licensed or registered physical, occupational or speech therapist

•   Home health aide working directly under the supervision of one of the above employees




                                                     22
•   Medical Social Worker (MSW).

Private duty nursing, shift or hourly care services, custodial care, maintenance care, housekeeping
services, respite care or meal services are not covered.

The home health care benefit is not intended to cover care in the home when care in a skilled nursing
facility or a hospital is determined by FCHA to be more cost-effective.


Hospice Care
Hospice care is covered when prescribed by your physician and the provider has determined life
expectancy is 6 months or less, and a palliative, supportive care treatment approach has been chosen.
Hospice care must be part of a written plan of care prescribed, periodically reviewed and approved by a
physician to be covered. Any charges for hospice care that qualify under this benefit and under any other
benefit of this Plan will be covered under the most appropriate benefit, as determined by FCHA.

Coverage for hospice care includes:

•   Medically necessary services and supplies in an inpatient or home hospice program approved by
    FCHA

•   Intermittent in-home visits when provided by an RN, LPN, MSW, physical, occupational or speech
    therapist or home health aide

•   1 period of continuous home care provided by an RN, LPN or home health aide under the supervision
    of an RN. This type of care is provided only during a crisis that would otherwise require
    hospitalization in an acute care facility. Continuous care is covered for 4 or more hours a day for a
    period not to exceed 5 days, or 72 hours, whichever comes first

•   Respite care is covered in the home in order to continue necessary care activities in the absence of a
    primary care giver. Coverage is limited to a maximum of 120 hours during each 3 months of hospice
    care, beginning with the first day of covered hospice care

•   Approved prescription drugs furnished and billed by an approved hospice agency or home health
    agency

•   Durable medical equipment (see preceding section).

Coverage for hospice care does not include the following:

•   Any service excluded under this Plan

•   Financial or legal counseling services

•   Housekeeping or meal services

•   Services not specifically listed as covered hospice services under this Plan

•   Services by a participant or the patient’s family or by volunteers




                                                     23
•   Spiritual or bereavement counseling

•   Supportive equipment such as handrails or ramps

•   Transportation

•   Custodial care or maintenance care, except that benefits will be provided for palliative care to the
    terminally ill patient subject to the stated limits.


Hospital Inpatient
Coverage for inpatient hospital care includes semiprivate room and board, operating room and anesthesia
services, radiology, lab and pharmacy services furnished by and used while in the hospital.


Hospital Outpatient
Coverage for outpatient hospital care includes outpatient surgery, procedures and services, operating
room and anesthesia services, radiology, lab and pharmacy services furnished by and used while at a
hospital or ambulatory surgical center.


Lab and Radiology Services
Lab and radiology services are eligible for coverage when ordered by a qualified health care practitioner
and obtained consistent with Plan benefits.


Mental Health Care
Inpatient, outpatient and professional services are covered for mental or psychiatric conditions. Please call
FCHA at 800-640-7682 for assistance in obtaining care.

There is no coverage under this provision for the following:

•   Alcohol addiction

•   Behavioral therapy

•   Chemical dependency

•   Chronic pain management, including biofeedback

•   Court-ordered assessments

•   Developmental delay disorders

•   Marriage and family therapy, in the absence of a mental health diagnosis

•   Residential treatment



                                                     24
•   Sensitivity training

•   Sexual dysfunction

•   Smoking cessation.

Office visits for medication checks will not count toward your outpatient visit maximum.


Organ and Bone Marrow Transplants
Basic benefits will be provided to an organ transplant recipient who is covered under this plan. In
addition, inpatient benefits will be provided for the donor of an organ for transplant to a recipient.
Benefits for the donor will be provided for surgical removal of the organ, beginning on the day of surgery
and continuing for up to 10 additional, consecutive days.

No benefits will be provided for organ selection, transportation or storage costs, when donor benefits are
available though other group health plan coverage or when government funding of any kind is provided or
when the recipient is not a participant of this Plan.

Provided the criteria for a transplant procedure are met, the following transplants are covered according to
the benefit:

•   Heart

•   Heart/lung

•   Lung

•   Kidney

•   Kidney/pancreas

•   Liver

•   Certain autologous and allogenic bone marrow transplants (including peripheral stem cell rescue).

(Coverage for cornea transplants is available under the Plan’s standard outpatient surgical benefits.)

Coverage for transplant services is based on the following criteria:

•   Your provider submits to FCHA written recommendation and supporting documentation

•   Your medical condition requires the requested transplant based on medical necessity

•   The requested procedure is not considered experimental or investigational for your condition

•   You are accepted into the approved facility’s transplant program and comply with all program
    requirements.




                                                     25
Please have your provider send a written request to FCHA to approve benefits for your transplant prior to
your inpatient admission. The request must include the results of the transplant evaluation. Send the
requests to First Choice Health Administrators Medical Management at 600 University St., Suite 1400,
Seattle WA 98101.

Recipient Services
Covered transplant recipient services include:

•   Medical and surgical services directly related to the transplant procedure and follow-up care

•   Diagnostic tests and exams directly related to the transplant procedure and follow-up care

•   Inpatient facility fees and pharmaceutical fees incurred while an inpatient

•   Medically necessary services and supplies directly related to the transplant procedure

•   Pharmaceuticals administered in an outpatient setting

•   Travel expenses.

Donor Services
Donor services are covered if:

•   The transplant procedure is approved by FCHA

•   The recipient is enrolled in the group plan

•   Expenses are for services directly related to the transplant procedure

•   Donor services are not covered under any other health plan or government program.

Covered donor expenses include:

•   Donor typing, testing and counseling

•   Donor organ selection, removal, storage and transportation of the surgical/harvesting team and/or the
    donor organ or bone marrow.

Organ donor expenses apply toward the recipient’s lifetime maximum benefit.

Transplant Exclusions
In addition to the limitations and exclusions elsewhere in this document, the following transplant services
are not covered:

•   Animal-to-human transplants

•   Artificial or mechanical devices designed to replace human organs



                                                    26
•   Complications arising from the donation procedure if the donor is not an participant

•   Prescription drugs dispensed after the recipient has been discharged from the transplant facility,
    except as may be covered under the prescription drug benefit

•   Meals and lodging

•   Organ transplants not specifically listed as covered transplants

•   Transplants considered experimental or investigational, as defined in this document, for the condition.

If you, as a participant, choose to donate an organ or bone marrow, donor expenses are not covered under
this Plan. However, complications arising from the donation are covered as any other illness to the extent
they are not covered under the recipient’s health plan.


Plastic and Reconstructive Services
Plastic and reconstructive services and procedures are covered only for the following conditions and are
subject to any applicable coinsurance:

•   To correct a functional deficit resulting from a congenital disease or anomaly.

•   For prompt repair of an accidental injury while the participant is covered under this Plan (the repair
    must be performed within 12 months of the initial injury)

•   To correct a functional physical disorder resulting from disease or a prior surgery (if the prior surgery
    would be eligible for coverage under this Plan)

•   For reconstructive breast surgery following a mastectomy that resulted from disease, illness or injury,
    including internal or external breast prosthesis; breast reconstruction on the non-diseased or non-
    injured breast is covered to make the healthy breast equivalent in size to the reconstructed breast.

Coverage does not include:

•   Cosmetic services, supplies or surgery to repair, modify or reshape a functioning body structure for
    the improvement of the patient’s appearance or self-esteem

•   Complications resulting from non-covered services

•   Orthognathic surgery, regardless of origin or cause

•   Dermabrasion, chemical peels or skin procedures used to improve appearance or to remove scars or
    tattoos.




                                                     27
Prescription Drugs
There is no designated pharmacy network or pharmacy benefit manager for this Swedish Grandfathered
Retiree Plan. Participants may use any licensed pharmacy to dispense provider-prescribed medications
including diabetic supplies. See the Schedule of Medical Benefits starting on page 13 for coverage
amount.

If your pharmacy requires payment at the time a prescription is filled and they do not submit claims
directly to FCHA, you may submit the detailed prescription receipt to FCHA. Each detailed prescription
receipt must include the following:

•   Patient name

•   Cost

•   Name of drug

•   Date prescription was filled

•   Quantity

•   Dosage.

Please write your participant ID number on each detailed prescription receipt and mail to the FCHA claim
address on your ID card.


Surgeon and Professional Services
Coverage applies to in-person visits only. Charges for care provided by phone, fax, e-mail, Internet or
telemedicine are not covered.


Rehabilitation Therapy
Coverage for physical therapy, speech therapy, occupational therapy and cardiac therapy for disabling
conditions other than neurodevelopmental disabilities is provided on an inpatient and outpatient basis
when all of the following conditions are met:

•   The services are medically necessary to restore and significantly improve function that was
    previously present but was lost due to an acute injury or illness

•   The services are not for palliative, recreational or relaxation therapy

•   The loss of function was not the result of a work-related injury

•   The therapy is provided by, or prescribed by, your physician.




                                                     28
Coverage for cardiac rehabilitation requires meeting all of the following conditions:

•   The services are under the supervision of a physician

•   The services are in connection with a myocardial infarction, coronary occlusion or coronary bypass
    surgery

•   The services are initiated within 12 weeks after other treatment for the medical condition ends.

Inpatient Rehabilitation
Inpatient rehabilitation services must be furnished and billed by a rehabilitative unit of a hospital, or be
furnished and billed by another rehabilitation facility approved by FCHA. When rehabilitation follows
acute care in a continuous inpatient stay, this benefit starts on the day that the care becomes primarily
rehabilitative. Inpatient care includes all room and board, all services provided and billed by the inpatient
facility, and therapies performed during the rehabilitative stay.

Outpatient Rehabilitation
Benefits for outpatient rehabilitation care are subject to the following provisions:

•   You must not be confined in a hospital or other medical facility

•   The therapy must be part of a formal written treatment plan prescribed by your physician

•   Services must be furnished and billed by a hospital, physician or physical, occupational or speech
    therapist.

Speech therapy is covered only when required as a result of brain or nerve damage secondary to an
accident, disease or stroke.

All therapies combined count toward the outpatient maximum.

Once the benefits under this provision have been exhausted, coverage may not be extended by using the
benefits under any other provision.


Skilled Nursing Facility (Combined With Inpatient Rehabilitation)
Medically necessary care in a skilled nursing facility for skilled care services is covered when prescribed
by your physician. Coverage for a skilled nursing facility includes semiprivate room and board and
ancillary services (remember all services and supplies must be medically necessary to be covered). The
care provided must be therapeutic or restorative and require in-facility delivery by licensed professional
medical personnel, under the direction of a physician, to obtain the desired medical outcome.

Maintenance care and custodial care are not covered.




                                                     29
Women’s Health and Cancer Rights Act of 1998 Disclosure
The Women’s Health and Cancer Rights Act of 1998 requires Swedish Health Services to disclose the
following benefit statement to participants:

Group health plans that provide medical and surgical benefits with respect to mastectomy resulting from
disease, illness or injury will provide, in a case of a participant receiving benefits in connection with a
mastectomy who elects breast reconstruction in connection with the mastectomy, coverage for the
following services in a manner determined in consultation with the physician and the participant:

•   Reconstruction of the breast on which the mastectomy has been performed

•   Reconstruction of the other breast to produce a symmetrical appearance

•   Internal or external prostheses

•   Treatment of physical complications in all stages of post-mastectomy reconstruction, including
    lymphedemas.




                                                     30
Medical Limitations and Exclusions
Covered services are limited to the diagnosis, therapeutic care or treatment, and prevention of disease,
sickness or injury as described in this Plan document. In addition to limits and exclusions stated
elsewhere in this Plan document, coverage is specifically excluded for each of the following items and
any related services and charges:

•   Abdominoplasty/panniculectomy

•   Acupuncture

•   Alternative care

•   Aromatherapy

•   Artificial insemination, in vitro fertilization, gamete intra-fallopian transplant (GIFT) or any other
    treatment for infertility (regardless of the cause), including any direct or indirect complications or
    after effects, other than pregnancy

•   Athletic training, body-building, fitness training or related expenses

•   Biofeedback

•   Botanical or herbal medicines, as well as other over-the-counter medications

•   Care provided by phone, fax, e-mail, Internet or telemedicine

•   Charges by a hospital owned or operated by, or that provides care or performs services for, the United
    States government, if such charges are directly related to a military-service-connected sickness or
    injury

•   Charges by an assistant surgeon in excess of 20% of the surgeon’s allowable charge or, for charges by
    a co-surgeon, in excess of the surgeon’s allowable charge plus 20% (for this limitation, allowable
    charge means the amount payable to the surgeon prior to any reductions due to coinsurance or
    deductible amounts)

•   Charges for or in connection with speech therapy, if such therapy is used to improve speech skills that
    have not fully developed, can be considered custodial or educational or is intended to maintain speech
    communication; speech therapy that is not restorative is not covered

•   Charges for services or supplies over and above UCR (see Plan Definitions)

•   Charges for unnecessary care, treatment or surgery

•   Charges that would not have been made if the person had no insurance

•   Charges the person is not legally required to pay

•   Chiropractic care


                                                     31
•   Cochlear implants

•   Cognitive therapy

•   Corrective shoes

•   Cosmetic services (surgical or non-surgical), including treatment for complications, except as covered
    by the Plan

•   Custodial care, maintenance care, domiciliary care, housekeeping services or rest cures

•   Dental services including, but not limited to, associated anesthesia or facility charges, except as
    covered by the Plan

•   Diagnosis or treatment of sleep disorders and snoring

•   Elective abortion

•   Expenses for which a participant is in any way paid or entitled to payment for, by or through a public
    program, other than Medicaid

•   Experimental or investigational (see Plan Definitions) services, procedures or treatment methods not
    approved by the American Medical Association, American Dental Association or appropriate medical
    or dental specialty society

•   Eyeglasses and contact lenses outside of the specific plan benefit for cataracts

•   Food supplements

•   Genetic testing, counseling, interventions or other genetic service, unless it is an essential component
    of a covered and medically necessary treatment or a medically necessary precursor to obtaining a
    prompt covered treatment

•   Growth hormone treatment

•   Hair analysis

•   Hearing evaluation, aids or appliances

•   Home births

•   Implants including, but not limited to, penile implant prostheses

•   Infertility treatments (regardless of the cause) including in vitro fertilization, artificial insemination or
    other similar procedures

•   Injury arising out of, or in the course of, any employment for wage or profit

•   Laser Assisted Uvuloplasty (LAUP), Laser Assisted Uvulopalatoplasty (LAUPP) or somnoplasty




                                                       32
•   Learning disabilities treatment, including educational training

•   Liposuction or other procedures for removal of adipose tissue

•   Marriage or family counseling, except as may be covered by the Plan

•   Massage or massage therapy

•   Naturopathic care

•   Non-covered services or complications arising from non-covered services (also see organ transplant
    limitations under Organ and Bone Marrow Transplants)

•   Occupational injuries or diseases

•   Oral appliances, except for the medically necessary non-surgical treatment of TMJ

•   Orthodontic appliances or services; dentures or related services

•   Orthognathic (jaw) surgery, regardless of the origin or cause, including any complications or after
    effects; treatment of malocclusion; upper or lower jaw bone surgery except for direct treatment of
    acute traumatic injury or cancer

•   Over-the-counter products

•   Payment that is unlawful where the person resides when the expenses are incurred

•   Personal, convenience or comfort services, supplies or items including, but not limited to, telephones,
    televisions, guest services, private hospital room, air conditioners, diapers or hygiene items

•   Physical exams for obtaining or continuing employment, insurance or government licensure

•   Physician charges for or in connection with surgery that exceed the following maximum when 2 or
    more surgical procedures are performed at one time: the maximum amount payable will be the
    amount otherwise payable for the most expensive procedure and ½ of the amount otherwise payable
    for all other surgical procedures

•   Prescription medications, except as covered by the Plan

•   Preventive care or screening

•   Private duty nursing

•   Procedures, regardless of medical necessity, outside the scope of the provider’s license, registration or
    certification

•   Radial keratotomy, Lasik or any other refractive surgery, orthoptics, pleoptics, visual analysis therapy
    or training related to muscular imbalance of the eye, or optometric therapy




                                                     33
•   Repair or replacement of items not used in accordance with manufacturer’s instructions or
    recommendations

•   Replacement of lost or stolen items, such as, but not limited to, prescription drugs, prostheses or
    DME

•   Respite care, except as covered under hospice benefits

•   Reversal of sterilization

•   Rhinoplasty

•   Routine eye exams

•   Routine foot care including, but not limited to, removal of calluses and corns or trimming nails unless
    medically necessary

•   Services for any condition for which the Veterans’ Administration, federal, state, county or municipal
    government or any of the armed forces is responsible or provides treatment, except as required by law

•   Services for any condition, illness or injury that arises from or during the course of work for wages or
    profit covered by State Insurance Workers’ Compensation and Federal Act or similar law

•   Services for any condition resulting from declared or undeclared acts of terrorism, war or military
    service

•   Services for mental health, except as may be covered by the Plan

•   Services for the care or treatment of pregnancy or complications of pregnancy for dependents

•   Services for the treatment of sexual dysfunction

•   Services or supplies that in general do not involve treatment of an illness or injury, including routine
    physical, mental or eye exams including eye exercises, routine test or screening procedures or well-
    baby/well-child care, unless covered by the Plan

•   Services or supplies to the extent benefits are payable under the terms of a contract or insurance
    offering for uninsured or underinsured (UIM) coverage, motor vehicle, motor vehicle no-fault or
    personal injury protection (PIP) coverage or commercial premises or homeowner’s medical premise
    coverage or other similar type of contract or insurance

•   Services provided by a family member (spouse, parent or child)

•   Services provided by or that could be provided by a spa, health club or fitness center, non-medical
    self-help or training (such as programs for weight control, programs to help stop smoking or general
    fitness exercise programs)

•   Services received prior to the participant’s effective date of coverage or after the coverage
    termination date




                                                     34
•   Services related to injuries while under the influence of a controlled substance and/or alcohol unless
    the controlled substance was prescribed by a physician

•   Services that are not medically necessary for the diagnosis, treatment or prevention of injury or
    illness, even though such services are not specifically listed as exclusions

•   Sex change operations or treatment for transsexualism; care, service or treatment of non-congenital
    transsexualism, gender dysphoria or sexual reassignment or change (this exclusion includes
    medications, implants, hormone therapy, surgery, medical or psychiatric treatment)

•   Smoking or tobacco cessation treatment programs

•   Special diets, nutritional supplements, vitamins and minerals or other dietary formulas or supplements
    (except PKU formula for the treatment of phenylketonuria (PKU), which is covered at 100%)

•   Special education for the developmentally disabled

•   Sterilization procedures or reversal of such procedures, except as covered by the Plan

•   Supplies, care, treatment or surgery not considered essential for the necessary care and treatment of
    an injury or sickness, as determined by FCHA

•   Surgery for gynecomastia

•   Surgical or non-surgical interventions for the treatment of obesity; services and supplies for weight
    loss or obesity

•   Surgical or other treatment for snoring

•   Transportation, except as covered by the Plan

•   Travel- or work-related immunizations or medications

•   Treatment of dyslexia

•   Use of FDA-approved drugs, medications or other items for non-approved indications, except when
    an FDA-approved drug has been proven clinically effective for the treatment of such indication and is
    supported in peer-reviewed scientific medical literature; or for drugs labeled “Caution – limited by
    federal law to investigational use”

•   Viagra

•   Vitamin B-12 injections except for the treatment of Vitamin B-12 deficiency

•   Vocational rehabilitation.




                                                    35
Covered Dental Services and Supplies
This section outlines the dental coverage available under this Plan and identifies the deductible and/or
coinsurance amounts for which you’re responsible. The benefits of this Plan are provided for covered
services at the specified percentages after the applicable deductible has been met. The dental benefit is a
percentage of the usual, customary and reasonable (UCR) charges for those dental services and supplies
listed under Dental Expenses below. This dental benefit does not use a dental provider network. Dental
benefits are administered by FCHA.

To help you budget for more expensive treatments like crowns and bridges, we recommend that you have
your dentist submit a pre-estimate any time charges are expected to exceed $500.


Annual Dental Deductible
The annual deductible is the amount you (or your family) must pay each calendar year before the Plan
pays covered services. Only covered services count toward the annual deductible. The amount due to a
provider remains your responsibility until your annual deductible is met.


Dental Expenses
Dental expenses mean the charges for dental services and supplies provided by your dental professional
and listed below. Expenses are covered only when the dental service:

•   Is performed by or under the direction of a licensed dentist

•   Is essential for the necessary care of the teeth

•   Starts and is completed while the person is insured.

A dental service is deemed to start when the actual performance of the service starts except that:

•   For fixed bridgework and full or partial dentures, it starts when the first impressions are taken and/or
    abutment teeth are fully prepared

•   For a crown, inlay or onlay it starts on the first date of preparation of the tooth involved

•   For root canal therapy, it starts when the pulp chamber of the tooth is opened.

Any portion of charges for a dental service that exceeds the maximum covered expense for that service is
not covered.




                                                       36
                                    Swedish Grandfathered Retiree Plan
Annual Dental Deductible                    Individual: $50 deductible
(applies to Class II and III dental care)
                                            2 family member deductible:
                                            $100 for you and your dependent
                                            3 family member deductible:
                                            $150 for you and your dependents
                                            Retired corporate employees: no deductible
Dental Coverage                             Class I: 100%
                                            Class II: 80%
                                            Class III: 50%
                                            Retired corporate employees: dental injuries covered at 100%
Maximum                                     $1,000 for Class I, II and III/calendar year
                                            Retired corporate employees: $2,000/calendar year


Coverage                                    Covered Features
Class I – 100% (no deductible)              Preventive and Diagnostic Dental Care – Diagnosis and
                                            evaluation of existing conditions and the dental care required
                                            including cleaning, exams and bitewing x-rays
                                            (twice/calendar year)
Class II – 80% after deductible             Basic Restorative Care – Fillings, extractions, root canal therapy,
                                            periodontics, endodontics, prosthodontic maintenance; oral
                                            surgery with IV sedation included; periodontal prophylaxis.
Class III – 50% after deductible            Major Restorative Care – Crowns, inlays, onlays, bridges,
                                            dentures, gold fillings and crown restorations; “best practices”
                                            administration for ADA Code 2950.



Class I Benefits – Preventive and Diagnostic Care
Class I includes charges for the following services and supplies:

•   Oral evaluations of the mouth and teeth twice each calendar year – no more than 1 charge in any
    consecutive 6 months

•   The following dental x-rays:

    – 1 set of full mouth or panoramic x-rays in 36 consecutive months
    – 1 set of bitewing x-rays – 1 charge in 6 consecutive months

•   Prophylaxis with or without oral exam twice each calendar year – 1 visit each consecutive 6 months

•   Space maintainers to preserve the space between teeth caused by premature loss of a primary tooth;
    orthodontic space maintainers are not included

•   Topical application of fluoride for a child up to age 19 once each calendar year when performed in
    conjunction with a prophylaxis – 1 application each consecutive 12 months.




                                                             37
Class II Benefits – Basic Restorative Care
Class II includes charges for the following services and supplies:

•   Amalgam, silicate, acrylic, synthetic porcelain and resins or composite filling material to restore teeth
    broken down by decay or injury

•   Fillings performed on posterior teeth using resins or composite filling material

•   Fillings performed on the following surfaces of anterior teeth – paid as single-surface fillings:
    mesiolingual, distolingual, mesibuccal and distobuccal

•   Endodontic treatment, including pulpotomy, apicoectomy, retrograde filling and root canal treatment

•   Simple, non-surgical extraction of 1 or more teeth

•   Oral surgery and postoperative treatment:

    – Surgical extraction of 1 or more teeth
    – Extraction of the tooth root
    – Alveolectomy, alveoplasty and frenectomy
    – Excision of a tumor or cyst and incision and drainage of an abscess or cyst
    – General anesthetics, analgesics and intravenous sedation when given as part of an oral surgery
      listed in this subsection

•   Periodontal services: surgical and non-surgical procedures for the treatment of the tissues supporting
    the teeth; covered services include root planing, subgingival curettage, gingivectomy and limited
    adjustments to occlusion (8 or fewer teeth) such as smoothing teeth or reducing cusps

    – Root planing or subgingival curettage (but not both) are covered once in 12 months
    – Limited occlusal adjustments are covered once in 12 months

•   Pin retention fillings

•   Recementing inlays, onlays and crowns

•   Recementing bridges

•   Dental consultations, but not more than twice in 12 months

•   Local anesthesia, analgesic and routine post-operative care for extractions and other oral surgery –
    part of the allowance for each dental service

•   General anesthesia – paid as a separate benefit only when medically or dentally necessary as
    determined by FCHA, and when administered in conjunction with complex oral surgical procedures
    covered under this Plan

•   Osseous surgery – flap entry and closure is part of the allowance for osseous surgery and graft and
    not a separate dental service; if more than 1 periodontal surgical service is performed per quadrant,
    only the one with the largest maximum covered expense is a dental service



                                                     38
•   Adjustments – complete denture; any adjustment of or repair to a denture within 6 months of
    installation is not a separate dental service

•   Periodontal prophylaxis.


Class III Benefits – Major Restorative Care
Class III includes charges for the following services and supplies:
•   Restorative services and supplies:

    – High noble metal (gold) or porcelain inlays, onlays, veneers and crowns but only when the tooth,
      because of extensive caries or fracture, cannot be restored with an amalgam, silicate, acrylic,
      synthetic porcelain or composite filling material
    – Crowns, inlays or onlays on the same teeth:
       • Porcelain fused to high noble metal
       • Full cast, high noble metal
       • Three fourths cast, metallic
    – Fixed or removable appliances:
       • Complete (full) dentures, upper and lower
       • Partial dentures – upper and lower; cast metal base with resin saddles (including any
         conventional clasps, rests and teeth)
•   Prosthetic services and supplies: dentures, bridges, partial dentures, related items and the adjustment
    or repair of an existing prosthetic device

•   Denture adjustments and relines done more than 6 months after the initial placement are covered;
    subsequent relines and jump rebases, but not both, are covered once in 12 months

•   Replacement of permanent devices

•   Bridge pontics – cast high noble metal

•   Bridge pontics – porcelain fused to high noble metal

•   Bridge pontics – resin with high noble metal

•   Abutment crowns – resin with high noble metal

•   Abutment crowns – porcelain fused to high noble metal

•   Abutment crowns – full cast high noble metal.

No dental benefit will be paid for any duplicate prosthetic appliance or the replacement of any lost,
missing or stolen prosthetic appliance.




                                                     39
Dental Limitations and Exclusions
In addition to limits and exclusions stated elsewhere, no dental benefit will be paid for the following
charges:

•   Analgesics (such as nitrous oxide or IV sedation) or any other euphoric drugs, injections drugs,
    except as covered under prescription drug benefits

•   Appliances or restorations to increase vertical dimension, to restore an occlusion or for gnathologic
    recordings

•   Application of desensitizing agents

•   Bite registrations, precision or semi-precision attachments or splinting

•   Charges exceeding the UCR that would have been charged had all required dental services and
    supplies been provided by the same dental professional, if you change dental professionals while
    receiving treatment or receive care from more than 1 dental professional for 1 dental procedure

•   Charges exceeding the UCR for the services or supplies provided; benefits will be reduced so that the
    total payment under the Plan will not be more than 100% of the UCR charges made for covered
    dental services

•   Charges for a broken appointment, completing insurance forms or patient management problems

•   Charges for dental services started prior to the date the person became eligible for services under this
    Plan

•   Crown lengthening

•   Dental expenses for which benefits are payable under any medical expense plan or under any liability
    policy including, but not limited to, an automobile policy or homeowner’s policy

•   Habit-breaking appliances or orthodontic services or supplies

•   Hospitalization charges and any additional fees charged by the dentist or hospital treatment

•   Instruction for plaque control, oral hygiene or diet

•   Lab exam of tissue specimen

•   Lingually placed direct bonded appliances and arch wires

•   Maxillofacial surgery, myofunctional therapy, cleft palate treatment or treatment of micrognathia or
    macrognathia

•   Medical expense plan or pre-paid treatment program sponsored or made available by your employer

•   Orthodontic services or supplies


                                                     40
•   Porcelain or acrylic veneers of crowns or pontics on or replacing the upper and lower first, second or
    third molars

•   Procedures, appliances or restorations (except full dentures) whose main purpose is to:

    – Change vertical dimension
    – Diagnose or treat conditions or dysfunction of the temporomandibular joint
    – Stabilize periodontally involved teeth
    – Restore occlusion.

•   Pulp capping or pulp vitality tests

•   Replacement of a bridge, crown or denture that is or can be made usable according to common dental
    standards

•   Replacement of a bridge, crown or denture within 5 years after it was originally installed unless:

    – Replacement is made necessary by the placement of an original opposing full denture or the
      necessary extraction of natural teeth
    – The bridge, crown or denture, while in the mouth, has been damaged beyond repair as a result of
      an injury received while a person is insured for these benefits
•   Replacement of lost or stolen appliances

•   Services or supplies for which benefits are not payable

•   Services or supplies for which no charge would be made in the absence of insurance or for which you
    are not obligated to pay

•   Services or supplies for which you are entitled to benefits under any workers’ compensation or
    similar law, or charges for services or supplies received as a result of any dental condition caused or
    contributed to by an injury or sickness arising out of or in the course of any employment for wage or
    profit

•   Services or supplies not generally accepted by the dental profession or that are experimental or
    investigational, or not necessary according to generally accepted standards of dental practice

•   Services or supplies other than the dental expenses listed in this Plan document

•   Services or supplies primarily for cosmetic purposes including, but not limited to, laminates or
    bleaching of teeth

•   Services or supplies received from a hospital

•   Services or supplies related to diagnosis or treatment of temporomandibular joint disorder or
    craniomandibular disorder

•   Services related to injuries while under the influence of a controlled substance and/or alcohol unless
    prescribed by a physician



                                                    41
•   Surgical implant of any type including any prosthetic device attached to it

•   Temporary dental service (such as a temporary crown) is included in the allowance for the final
    dental service and is not considered a separate service

•   Tooth transplants

•   Treatment of fractures; orthognathic surgery.




                                                    42
Termination of Coverage
If you or your dependents lose coverage under this Plan, you may be eligible to continue coverage.
For more information, please read the COBRA section of this Plan document.

Coverage is automatically extended through the last day of the month of termination, provided the
applicable contribution for the coverage period has been paid. Retiree participants and dependents receive
a certificate of creditable coverage that shows the period of coverage under this Plan. (Contact the
Benefits Department for further details.)

Any of the following will cause coverage to terminate on the earliest date below:

Retiree participant:

•   Death

•   Non-payment of the contribution, when payment is the responsibility of the retiree participant –
    coverage ends the last day of the month for which you have made any required contributions

•   Divorce or legal separation

•   With respect to a dependent child, failure to meet eligibility requirements for coverage – coverage
    ends the last day of the month following the date you cease to be eligible

•   The date the retiree participant cancels coverage under the Plan

•   Termination of the Plan by the Plan Sponsor.

Dependent:

•   The date the retiree participant terminates coverage

•   The last day for which the retiree participant or dependent has made any required Plan contributions

•   The retiree participant dies

•   The retiree participant and spouse legally divorce or legally separate (the retiree needs to submit a
    copy of the legal divorce decree to the Benefits Department)

•   The date a dependent child exceeds the dependent child limiting age, unless meeting the requirements
    for disabled child

•   The date a dependent child marries.

Enrollment into this Plan is a plan year commitment. You can change elections mid-year if you have a
qualifying event (see page 71 for definition). Swedish Health Services requires 31 days written notice of
dependent termination.




                                                     43
Effect of Employer Chapter 11 Proceedings on Retiree Coverage
If you are covered as a retiree, and a proceeding under USC Chapter 11 bankruptcy for the employer
results in a substantial loss of coverage for you or your dependents within 1 year before or after the
proceeding, coverage will continue until:

•   For you: your death

•   For your dependent spouse or dependent child: up to 36 months from your death.




                                                    44
Consolidated Omnibus Budget Reconciliation
Act of 1985 (COBRA)
If your coverage terminates under this group health plan, you may be eligible under COBRA to continue
the same coverage you had when coverage ended, on a temporary self-pay basis. COBRA requires this
continuation of coverage be made available to covered persons – called qualified beneficiaries under
COBRA – on the occurrence of a qualifying event, described on the next page.

Continuation of coverage under COBRA is not automatic; you must elect COBRA by completing an
enrollment form. You must contact your Plan Administrator (the Benefits Department) and apply for
continuation of your group health plan coverage within 60 days of the termination of coverage. You will
also be required to pay applicable contributions for you and/or your dependent(s) directly to Swedish
Health Services.

This section describes your COBRA coverage rights; contact the Benefits Department for more
information.


Who Is a COBRA Qualified Beneficiary?
Swedish Health Services group health plan participants may be eligible for COBRA in the case of a
qualifying event if they are also a qualified beneficiary. Qualified beneficiaries include:

•   Retiree participants enrolled in the Swedish Grandfathered Retiree Plan on or before the date of the
    event that causes them to lose that coverage (called the qualifying event)

•   A retiree participant’s spouse enrolled in this Plan on the day before the qualifying event

•   A retiree participant’s dependent children enrolled in this Plan on the day before the qualifying event

•   Dependent children born to, or placed for adoption with, the retiree participant while the retiree has
    COBRA coverage

•   Dependent children acquired through legal guardianship while the retiree participant has COBRA
    coverage

•   Dependent children covered under medical child support orders while the retiree participant has
    COBRA coverage.

Certain qualified beneficiaries may have additional COBRA rights and possible tax credits if they’re
certified by the Department of Labor or state labor agencies as eligible under the Trade Adjustment
Assistance Reform Act of 2002. (Contact the Plan Administrator for more details.)




                                                     45
Qualifying Events and Continuation Periods
Qualifying events and continuation periods are explained below:

•   If a retiree participant and spouse legally divorce or are legally separated, the retiree’s spouse and
    their covered dependent children may continue coverage under this Plan for up to 36 months.

•   When a retiree participant’s covered dependent child no longer meets the Plan’s definition of
    dependent child, the child may continue coverage under this Plan for up to 36 months.

•   If the retiree participant dies, covered dependents may continue coverage under this Plan for up to
    36 months.


When COBRA Coverage Ends
COBRA coverage ends before the 36-month period expires for any of these reasons:

•   Swedish Health Services no longer provides group health coverage

•   The COBRA coverage premium is not paid within 30 days of the due date (the initial grace period is
    45 days after the first COBRA election)

•   The qualified beneficiary becomes covered under another group health plan with no applicable pre-
    existing condition exclusion or limit.

Once COBRA coverage ends, it cannot be reinstated.


Contribution Payment Requirements
As a retiree participant, you are required to pay any and all applicable contributions for you and your
covered dependents. You must pay the first contribution for continuation of coverage within 45 days of
the date you elect COBRA coverage. Contributions consist of the full cost of coverage, plus 2% (a total
of 102%).

If the cost for similarly situated active employees or dependents changes, your COBRA coverage
premium also changes.

Failure to make payments within the designated time frame will result in automatic termination of
coverage to the last day of the month for which a complete payment was made. All these payments need
to be sent directly to First Choice Health Administrators (refer to your FCHA ID Card).




                                                     46
Election Requirements
In the case of divorce, legal separation or the ineligibility of a dependent child, the qualified beneficiary is
responsible for notifying the Swedish Health Services Benefits Department (Plan Administrator) within
60 days of the qualifying event or the last day of coverage. Swedish Health Services is not obligated to
offer COBRA benefits to beneficiaries if this notification isn’t received within the 60 days.

At the time of a qualifying event, the qualified beneficiary must be notified of the right to continue
coverage within 14 days of FCHA receiving notice of the qualifying event from the Plan Administrator.


What Coverage Must Be Offered When Electing COBRA?
The Plan is required to continue the following coverage for COBRA participants:

•   Identical coverage – the qualified beneficiary must be offered the opportunity to continue the
    coverage received immediately before the qualifying event.

•   Independent rights – once a qualifying event occurs each qualified beneficiary has an independent
    right to elect continuation coverage. For example, if a retiree participant and family are offered
    COBRA coverage, each individual can make an election.

•   Open enrollment – qualified beneficiaries have the same rights as other participants during open
    enrollment to add or drop family members, change coverages and change carriers, if available. If a
    qualified beneficiary adds a family member during open enrollment who was not previously covered,
    that added family member does not become a qualified beneficiary. Qualified beneficiaries must be
    notified of any benefit or carrier changes at open enrollment.

•   Modification of coverage – if the employer modifies coverage for the Swedish Grandfathered Retiree
    Plan, the coverage for qualified beneficiaries must be modified similarly. Some examples of
    modifications include benefit enhancements, elimination of coverage and changes in carriers.


Group Health Plan Qualified Status Changes
                                     Qualifying Event                                     Medical Benefits
You marry, divorce or become legally separated, or your marriage is annulled                     Yes
Your child gains or loses eligibility (for example, by exceeding the limiting age)               Yes
You acquire a new child (by birth, adoption, placement, etc.)                                    Yes
Your spouse or child dies                                                                        Yes
Your spouse starts or stops working                                                              Yes
You, your spouse or child becomes eligible for or loses coverage under a government              Yes
institution, Medicare, Medicaid or a state children’s health program




                                                            47
Coordination of Benefits
Benefits Subject to the COB Provision
The benefits provided under this Plan do not duplicate other coverage you, your dependent(s) or Swedish
Health Services may have for medical care or treatment. The purpose of this COB provision is to ensure
the total of claim benefits paid by the Plan and other plans with concurrent coverage does not exceed
100% of the net payable amount under this Plan in the absence of another plan.

The following formula is used in calculating benefits when COB applies:

•   Allowed amount – minus any coinsurance, deductible, non-covered expense, withhold amount and
    primary plan (the plan that pays benefits first; see below) payment – equals FCHA’s net payment.

When a participant fails to use another group plan that is primary, this Swedish Health Services Plan, as
secondary, will not assume liability for those charges. Any medical expense plan or pre-paid treatment
program sponsored or made available by another employer is primary to this Plan.

If the Plan pays benefits as primary when another plan is actually primary, the Plan will exercise the right
to recover those paid amount(s).

All covered benefits provided under the Plan are subject to this COB provision.


Determination of Plan Priority
If you or your dependents have medical, dental or prescription drug coverage in addition to this Swedish
Grandfathered Retiree Plan, the rules described in this section govern COB with your other coverage.
(Other coverage includes another employer’s group benefit plan, Medicare (to the extent allowed by law),
individual insurance or health coverage and insurance that pay without consideration of fault.)

The primary plan pays benefits first, without regard to benefits that may be payable under other plans.
When another plan is primary for medical coverage, the secondary plan pays the difference between
benefits paid by the primary plan and what would have been paid if the secondary plan were primary.
A plan is considered primary if:

•   It has no rules for order of benefit determination

•   It has rules for order of benefit determination that differ from COB rules

•   All plans covering an individual use the same COB rules and, under those rules, the plan is primary.

If the rules above don’t determine which group plan is primary, this Plan will apply these COB rules:

•   A plan covering a person as an active employee, retiree, member or subscriber pays before a plan
    covering a person as a dependent.




                                                     48
•   A plan covering a person as an employee or dependent of an active employee is primary. A plan
    covering a person as retired, laid-off or other inactive employee or dependent of a retired, laid-off or
    other inactive employee is secondary.

•   For a dependent child covered under both parents’ plans, the child’s primary coverage is provided
    through the plan of the parent whose birthday comes first in the calendar year, with secondary
    coverage through the plan of the parent whose birthday comes later.

•   If a dependent child’s parents are divorced or separated and a court decree establishes financial
    responsibility for the child’s health care coverage, the plan of the parent with that financial
    responsibility is primary. If the divorce decree is silent on coverage, the plan of the:

    – Parent with custody pays first
    – Spouse of the parent with custody pays second
    – Parent without custody pays third
    – Spouse of the parent without custody pays fourth.

•   If none of the rules above establishes which plan should pay first, the plan that has covered the person
    the longest is primary.

•   Continuation of coverage under COBRA always is secondary to other coverage, except as required
    by law.

•   If you or an eligible dependent is confined to a hospital when first covered under this Swedish Health
    Services Plan, it’s secondary to any plan already covering you or your dependent for the eligible
    expenses related to that hospital admission. If you or your dependent doesn’t have other coverage for
    a hospital and related expenses, this Plan is primary.

Federal rules govern coordination with Medicare benefits. In most cases, Medicare is secondary to a plan
that covers a person as an active employee or dependent of an active employee. Medicare is primary in
most other circumstances.

Treatment of end-stage renal disease is covered by this Plan’s medical benefits for the first 30 months
after Medicare entitlement due to end-stage renal disease, and Medicare provides secondary coverage.
After these 30 months, Medicare is primary and this Plan’s coverage is secondary.


Meaning of Plan for COB
For COB purposes, the term “plan” means any agreement for benefits or services from any of the
following sources for medical or other covered health care services:

•   This Swedish Health Services Plan (the Plan with a capital “P”)

•   Any group, individual or blanket disability insurance policy

•   Any group or individual contractual pre-payment or indemnity plan such as those issued by health
    care service contractors, health maintenance organizations and other health carriers




                                                     49
•   Any labor-management trustee plan or union welfare plan

•   Any employer or multi-employer plan or employee benefit plan

•   Any government program

•   Any insurance coverage required or provided by statute

•   Any insurance coverage resulting from an act of negligence or omissions on the part of a third party

•   Auto insurance including uninsured motorist

•   Any other similar source.

Each health contract or other arrangement for benefits or services from one of the above sources is
considered a plan under COB.


Claim Determination Period
The claim determination period used when applying this COB provision is the calendar year, January 1
through December 31.


Right of Recovery
This provision does not reduce the benefits allowed under this agreement when this Plan is the primary
plan. However, if the Plan pays in excess of the maximum necessary at the time to satisfy the intent of
this COB provision, the Plan will exercise the right to recover the excess payments from any person(s),
insurer(s) or other organizations, as the Plan deems appropriate.


Facility of Payment
When another plan makes payments that should have been made under this Plan and in accordance with
this provision, the Plan may, at its sole discretion, elect to reimburse to the other plan the amount
necessary to satisfy the intent of this COB provision. Any amount paid under this subsection will be
considered benefits paid under this agreement, and the Plan will be fully discharged from liability under
this agreement to the extent of those payments.


Right to Receive and Release Information
The Plan Administrator and TPA may, with consent as required by law, receive or release to another
insurer or organization any information concerning the participant and covered benefits deemed necessary
to implement and determine the applicability of this COB provision.

The Plan Administrator and TPA have the right to require the participant to complete and return a
Multiple Coverage Inquiry when primary liability is not clearly established or to verify that multiple
coverage information on hand is accurate. Claim payment will be withheld until the Multiple Coverage
Inquiry is complete and received by FCHA (the TPA).



                                                    50
Subrogation
Liable Third Parties and Insurers
If the Plan makes payments on your behalf for injury or illness another party is liable for, or injury or
illness covered by uninsured/underinsured motorists (UIM) or personal injury protection (PIP) insurance,
the Plan is entitled to be repaid for those payments out of any recovery from that liable party. (The liable
party is also known as a third party because it’s a party other than you or the Plan, including your UIM
and PIP carriers because they stand for a third party and because the Plan excludes coverage for such
benefits.) Subrogation means the Plan can collect directly from third parties, to the extent the Plan has
paid for illness or injury caused by the third party, to recover those expenses.

To the fullest extent permitted by law, the Plan is entitled to the proceeds of any settlements or judgments
that result in the recovery from a first or third party, up to the amount of benefit paid by the Plan for the
condition. In recovering those amounts, the Plan Administrator (Benefits Department), Plan Sponsor
(Swedish Health Services) and/or TPA (FCHA) may either hire their own attorney or be represented by
your attorney. If the Plan chooses to be represented by your attorney, the Plan will pay, on a contingent
basis, a reasonable portion of the attorney’s fees necessary for asserting right of recovery in the case. This
portion will not exceed 20% of the amount the Plan seeks to recover. The Plan will not pay for any legal
costs incurred by or for you, and you won’t be required to pay any portion of the costs incurred by or for
the Plan.

Before accepting any settlement on your claim against a third party, you must notify FCHA’s Subrogation
Department in writing of any terms or conditions offered in a settlement, and you must notify the third
party of the Plan’s interest in the settlement (established by this provision). You must also cooperate with
the Plan in recovering amounts paid on your behalf. If you retain an attorney or other agent to represent
you in the matter, you must require your attorney or agent to reimburse the Plan directly from the
settlement or recovery proceeds. Notify the FCHA Subrogation Department at PO Box 12659, Seattle
WA 98111-4659 (800-750-5202, local: 206-268-2360, fax: 888-206-3092).

To the maximum permitted by law, the Plan is subrogated to your rights against any third party
responsible for the condition, meaning the Plan has the right to:

•   Sue the third party in your name

•   Have a security interest in and a lien on any recovery to the extent of the benefit amount paid by the
    Plan and for its expenses in obtaining a recovery

•   Recover benefits directly from the third party.

However claims, recoveries, etc. are classified or characterized by the parties, the courts or any other
entity will not affect your responsibilities described above or the Plan’s entitlement to first dollar
recovery, regardless of whether you are made whole.




                                                      51
Uninsured/Underinsured Motorist Coverage
If the Plan pays for services also covered by uninsured/underinsured motorist coverage, despite the
exclusion above, the Plan has the right to be reimbursed for benefits provided from any proceeds of that
UIM or PIP coverage.


Venue
All suits or legal proceedings (including arbitration proceedings) brought against the Plan by a participant
or anyone claiming any right under this contract, and all suits or legal proceedings brought by the Plan
against a participant or other party, will be filed within the appropriate statutory period of limitation. In all
suits or legal proceedings brought by the Plan or brought against the Plan, venue may lie, at the Plan’s
option, in King County, State of Washington.


Subrogation Forms
The participant will be required to complete an Incident Response Questionnaire and a Subrogation
Agreement form when details of the injury or condition do not clearly indicate if there is third party
liability. Claims are denied 30 days after the forms have been mailed if they are not both completed and
returned in their entirety, and until the Incident Response Questionnaire and Subrogation Agreement
forms are completed and returned.




                                                       52
Health Insurance Portability and Accountability
Act of 1996
Privacy Rights
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides you certain rights
with respect to the use and disclosure of your protected health information. For details on HIPAA privacy
standards, contact the Benefits Department for a copy of the Swedish Health Services HIPAA Privacy
Notice.




                                                   53
Plan Benefit Information
Benefits and Contributions
This Plan provides eligible retirees and dependents with medical (including prescription drugs) and dental
benefits, as summarized in this document. The cost of benefits provided through the Plan will be funded
in part by Swedish Health Services contributions and in part by participant contributions. Swedish Health
Services will determine and periodically communicate your share of the cost for these benefits, and may
change that determination at any time.

Swedish Health Services will make employer contributions in an amount that, at Swedish’s sole
discretion, is at least sufficient to fund the benefits or a portion of the benefits not otherwise funded by
your contributions, then use these contributions to pay benefits directly to or for participants from
Swedish general assets. Your contributions will be used in their entirety before using Swedish Health
Services contributions to pay for the cost of such benefit.

The Plan will provide benefits in accordance with the requirements of all applicable laws, such as
Consolidated Omnibus Budget Reconciliation Act of 1985, Health Insurance Portability and
Accountability Act of 1996, Newborns’ and Mothers’ Health Protection Act of 1996 and Women’s
Health and Cancer Rights Act of 1998.


Benefits Under Qualified Medical Child Support Orders
The Plan will provide benefits as required by any QMCSO (defined in ERISA §609(a)) including benefits
for adopted children (see below), in accordance with ERISA §609(c).

The Plan has detailed procedures for determining whether an order qualifies as a QMCSO. You can
obtain, without charge, a copy of those procedures from the Plan Administrator (the Benefits
Department). (Also see Qualified Medical Child Support Orders on page 7.)


Benefits for Adopted Children
The Plan will extend benefits to dependent children placed with you for adoption under the same terms
and conditions as for dependent natural children. (For other information regarding dependent eligibility,
see page 5.)


Special Rights – Childbirth Hospitalization
Group health plans generally may not, under federal law, restrict benefits for any hospital length of stay in
connection with childbirth for the mother or newborn child to less than 48 hours following a normal
vaginal delivery or less than 96 hours following a cesarean section. However, federal law generally does
not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from
discharging the mother or newborn earlier than these periods. In any case, the Plan may not, under federal
law, require that a provider obtain authorization from the Plan or the insurance issuer or TPA for
prescribing a length of stay not in excess of these periods.



                                                      54
Claim and Appeal Procedures
How to File a Claim for Plan Benefits
In most cases, network providers, hospitals and licensed pharmacies submit claims for you, and there are
no claim forms for you to complete. If you do receive a bill for services from a provider, write your name,
participant ID number and group number on the bill and send a copy to the claim address on your ID card.
(Your group number is also printed on your ID card.) Any bill you submit must contain:

•   Provider name

•   Provider tax ID information

•   Specific dates of service

•   Diagnosis codes (ICD-9 codes) or description of the symptoms or a diagnosis

•   Specific procedure codes (CPT codes) or description of the medical service or procedure.

It’s best to submit charges as soon as possible. However, you must submit charges for covered services or
supplies to FCHA within 12 months from the date the service or supply was received or claims will not be
considered for benefits. (See your ID card for the FCHA claim address.) Claim forms are available from
your Plan Administrator (the Benefits Department).

A claim means any request for a Plan benefit made by you (claimant) or your authorized representative
(an individual acting on behalf of the claimant in obtaining or appealing a benefit claim). The authorized
representative must have a signed form by the claimant (except for urgent care benefits or urgent care
appeals). Once an authorized representative is selected, all information and notifications should be
directed to that representative until the claimant states otherwise.


Claim Types
•   Pre-service claim means any claim for a Plan benefit for which the Plan requires approval before
    medical care is obtained.

•   Concurrent claim means any claim reconsidered after initial approval for an ongoing course of
    treatment that results in a reduced or terminated benefit.

•   Post-service claim means any claim for a Plan benefit that is not a pre-service claim and is a request
    for payment or reimbursement for covered services already received.

•   Urgent care claim means a claim for medical care or treatment that, if normal pre-service standards
    are applied:

    – Would seriously jeopardize the claimant’s life, health or ability to regain maximum function




                                                    55
    – In the opinion of a physician with knowledge of the claimant’s medical condition, would subject
      the claimant to severe pain that cannot be adequately managed without the care or treatment
      requested.
Adverse benefit determination means a denial, decrease or ending of a benefit. This includes a failure to
provide or make payment (in whole or in part) for a benefit including claims based on medical necessity
or experimental and investigational exclusions.


Claim Procedure
Swedish Health Services delegates to FCHA the authority, responsibility and discretion to:

•   Determine all questions of eligibility and status under the Plan

•   Interpret and construe Plan provisions, as necessary

•   Reach factually supported conclusions

•   Make a full and fair review of each denied claim under ERISA requirements, as amended.

FCHA will notify the claimant in writing of its decision on review.

All claims for benefits are subject to a full and fair review within a reasonable time appropriate to the
medical circumstances. Payment of any benefits is subject to the applicable deductibles, coinsurance and
benefit maximums.

The different claim types listed in the preceding subsection have specific times for approval, payment,
request for information or denial, as shown below:

                    Time Table for Adverse Benefit Determinations for Claim Procedures
                        FCHA Notice of      FCHA Notice of
                        Incorrectly Filed   Incomplete
Type of                 Claim – Notice      Claim – Notice      Initial Benefit Determination
Review                  to Claimant         to Claimant         by FCHA
Pre-Service Claim       5 days              Not required        Reasonable period = 15 days
                                            (may be part of
                                            extension notice)   15-day extension with notice to claimant
                                                                Reasonable period suspended up to
                                                                45 days on incomplete claim
Concurrent Claim        N/A                 N/A                 In time to permit appeal and determination
                                                                before treatment ends or is reduced
Post-Service Claim      N/A                 Not required        Reasonable period = 30 days
                                            (may be part of
                                            extension notice)   15-day extension with notice to claimant
                                                                Reasonable period suspended up to 45
                                                                days on incomplete claim
Urgent Care Claim       24 hours            24 hours            72 hours
                                                                No extensions from claimant




                                                         56
If your claim is denied wholly or in part, you will receive a written adverse benefit determination notice
that includes:

1. The specific reason or reasons

2. Reference to the specific Plan provisions on which the determination is based

3. Reference to any internal rule, guideline, protocol or similar criterion relied upon in making the
   decision

4. If the denial is based on medical necessity, experimental or investigational treatment or other similar
   exclusion or limit, the following will be provided:

    – Explanation of the scientific or clinical judgment used in making the decision
    – Statement that an explanation will be provided free, upon request
5. A description of any additional material or information needed to support your claim and an
   explanation of why it’s needed

6. Appropriate information on steps to take if you want to submit the claim for appeal review.


Appeal Procedure
If your claim is denied wholly or in part, you have the right to appeal this adverse benefit determination in
writing by following the appeal procedure listed below:

1. You must file your appeal within 180 days of the date you receive the adverse benefit determination
   or else you lose the right of appeal.

2. You may submit written comments or questions, documents, records and other information including
   the reason you feel your claim should not have been denied.

3. On request, you may obtain reasonable access to and copies of all documents, records and
   information relevant to your claim for benefits, free of charge.

4. You may request the name of the health care expert who reviewed your claim for medical necessity or
   experimental or investigational care or treatment.

5. You must exhaust these claim procedures before filing a civil action for benefits under ERISA
   §502(a)(1)(b); the civil action must be filed within 730 days from your receipt of the Plan’s final
   determination regarding your claim.




                                                     57
A time table for processing and notification of appeal procedures for each claim type follows:

                    Time Table for Processing and Notification of Appeal Procedures
Type of Review            Appeal (Benefit Determination on Review and Notification to Claimant)
Pre-Service Claim         Reasonable period = 30 days
                          No extension from claimant
Concurrent Claim          Before treatment ends or is reduced
Post-Service Claim        Reasonable period = 60 days
                          No extension from claimant
Urgent Care Claim         72 hours
                          No extension from claimant

Urgent care appeals will be expedited within 72 hours of receiving the appeal. The appeal may be oral or
written.

Once an urgent care appeal is completed, the claimant will be offered the standard appeal process. The
claimant has 180 days to file the standard appeal.

The appeal process will take into account all comments, documents, records and other information offered
that relates to the claim, which may include information not offered previously. The standard appeal
review will be a fresh look at your claim without considering the initial denial. The appeal review is
conducted by persons who are neither involved in the initial decision nor assistants to the person who
made the initial decision.

FCHA performs functions associated with the appeal process for this Plan. Swedish Health Services does
not provide a voluntary alternative dispute resolution option.

If the decision is to uphold the denial of your claim, you will receive a written notice of adverse benefit
determination containing:

•   The specific reason or reasons

•   Reference to the specific Plan provisions on which the determination is based

•   Reference to any internal rule, guideline, protocol or similar criterion relied upon in making
    the decision

On request you may obtain reasonable access to and copies of all documents, records and information
relevant to your claim for benefits, free of charge.

If the denial is based on medical necessity, experimental or investigational treatment or other similar
exclusion or limit, the following will be provided:

•   Explanation of the scientific or clinical judgment used in making the decision

•   Statement that an explanation will be provided free, upon request.




                                                        58
You have a right to file a civil action for benefits under ERISA §502(a)(1)(b) after you exhaust these
claim procedures; the civil action must be filed within 730 days from your receipt of the Plan’s final
determination regarding your claim.

Send written requests for appeal to FCHA Appeals Specialist, 600 University Street, Suite 1400, Seattle
WA 98101.

For urgent care appeals, you may call the Appeals Specialist at 800-808-0450.




                                                    59
Plan Administration
Funding
This Plan is an employer-sponsored self-funded group health benefit plan with administration provided
through a third party administrator (TPA). The funding for benefits is derived from the Plan Sponsor’s
general assets and contributions made by Plan participants.


Plan Administrator’s Power of Authority
The Plan Administrator role for this Plan rests with the Swedish Health Services Benefits Department.
The Plan Administrator is responsible for:

•   Determining eligibility for and the amount of any benefits payable under the Plan

•   Prescribing procedures to be followed and forms to be used by participants in this Plan.

The Plan Administrator may delegate any of these administrative duties among one or more entities, in
writing. The written delegation must describe the nature and scope of the delegated relationship.

The Plan Administrator has the authority to amend or eliminate benefits under the Plan. The Plan
Administrator also has the authority to require employees and retirees to furnish it with such information
as it determines is necessary for proper administration of the Plan.

The Plan Administrator will administer this Plan in accordance with its terms and establish its policies,
interpretations, practices and procedures.

An individual or individuals may be appointed by the Plan Sponsor, Swedish Health Services, to serve as
Plan Administrator at the convenience of the Plan Sponsor. If a Plan Administrator resigns, dies or is
otherwise removed from the position, Swedish Health Services will appoint a new Plan Administrator as
soon as reasonably possible.


Discretionary Authority
The Plan Administrator has the discretionary authority to interpret the Plan and to resolve any ambiguities
under the Plan. The Plan Administrator also has the discretionary authority to make factual
determinations as to whether any individual is entitled to receive benefits under this Plan and to decide
questions of Plan interpretation and of fact relating to the Plan. Plan Administrator decisions will be final
and binding on all interested parties.


Collective Bargaining Agreements
You may contact the Plan Administrator to determine where the Plan is maintained under one or more
collective bargaining agreements. A copy is available from the Plan Administrator, upon written request,
for examination.




                                                     60
Clerical Error
Any clerical error by Swedish Health Services, the Plan Administrator or an agent of the Plan
Administrator in keeping pertinent records or a delay in making any changes will not invalidate coverage
otherwise validly in force or continue coverage validly terminated. An equitable adjustment of
contributions will be made if the error or delay is discovered.

If, due to a clerical error, an overpayment occurs in a Plan reimbursement amount, the Plan retains the
contractual right to the overpayment. The person or institution receiving the overpayment will be required
to return the incorrect amount to the Plan through FCHA. In the case of a Plan participant, if it is
requested, the amount of overpayment will be deducted from future benefits payable.


Waiver of Group Health Plan Benefits
An eligible retiree may elect to waive participation in the group health plan. Once coverage under this
health plan is waived, it may not be reinstated.

Retirees who waive coverage must complete the enrollment form stating that they choose to waive
coverage. A retiree who waives coverage may not enroll their dependents. A dependent is not eligible for
coverage without the eligible retiree also enrolled.




                                                    61
Statement of ERISA Rights
As a participant in the Plan, you are entitled to certain rights and protection under the Employee
Retirement Income Security Act of 1974. ERISA provides that all Plan participants will be entitled to:

•   Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as
    work sites, all documents governing the Plan, including insurance contracts, and a copy of the latest
    annual report (Form 5500 Series), if any, filed by the Plan with the US Department of Labor and
    available at the Public Disclosure Room of the Employee Benefits Security Administration (formerly
    Pension and Welfare Benefits Administration).

•   Obtain, on written request to the Plan Administrator, copies of documents governing the operation of
    the Plan, including insurance contracts, collective bargaining agreements, copies of the latest annual
    report (Form 5500 Series) and an updated plan description. The Plan Administrator may make a
    reasonable charge for the copies.

•   Receive a summary of the Plan’s annual financial report, if any is required by ERISA to be prepared.
    The Plan Administrator is required by law to furnish each participant with a copy of this summary
    annual report.


Prudent Actions by Plan Fiduciaries
In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are
responsible for the operation of the benefit plan. The people who operate your Plan, called “fiduciaries”
of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and
beneficiaries. No one, including your employer or any other person, may fire you or otherwise
discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your
rights under ERISA.


Enforce Your Rights
If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why this was
done, to obtain copies of documents relating to the decision without charge, and to obtain any denial, all
within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For
instance, if you request materials from the Plan and do not receive them within 30 days, you may file suit
in a federal court. In such a case, the court may require the Plan Administrator to provide the materials
and pay you up to $110 a day until you receive the materials, unless the materials were not sent because
of reasons beyond the Plan Administrator’s control. If you have a claim for benefits that is denied or
ignored, in whole or in part, you may file suit in a state or federal court.

If it should happen that Plan fiduciaries misuse the Plan’s money, or if you are discriminated against for
asserting your rights, you may seek assistance from the US Department of Labor, or you may file suit in a
federal court. The court will decide who should pay court costs and fees. If you are successful, the court
may order the person you have sued to pay these costs and fees. If you lose, the court may order you to
pay these costs and fees, for example, if it finds your claim frivolous.




                                                    62
Continue Group Health Coverage
You may continue health care coverage for yourself, spouse or dependents if there is a loss of coverage
under the Plan as a result of a qualifying event. You or your dependents may have to pay for such
coverage. Review this Plan document and the documents governing your COBRA continuation coverage
rights.

You are entitled to a reduction or elimination in coverage exclusion periods for pre-existing conditions
under your health plan if you have creditable coverage from another plan. You should receive a certificate
of creditable coverage, free of charge, from your group health plan or health insurance issuer when you
lose coverage under the Plan, when you become entitled to elect COBRA continuation coverage, when
your COBRA continuation coverage ceases, if you request if before losing coverage or if you request it up
to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a pre-
existing condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in
your new coverage.


Assistance With Your Questions
If you have questions about your Plan, contact the Plan Administrator. If you have any questions about
your rights under ERISA or HIPAA, or if you need assistance in obtaining documents from the Plan
Administrator, contact the nearest office of the Employee Benefits Security Administration, US
Department of Labor, listed in your phone directory or:

The Division of Technical Assistance and Inquiries
Employee Benefits Security Administration, US Department of Labor
200 Constitution Avenue NW
Washington DC 20210

You may also obtain certain publications about your rights and responsibilities under ERISA by calling
the publication hotline of the Employee Benefits Security Administration.




                                                   63
Summary Plan Description and General
Information

Plan Name:                   Swedish Health Services Grandfathered Retiree Plan

Plan Year:                   January 1 through December 31

Type of Plan:                Group health plan (a type of welfare benefit plan subject to ERISA
                             provisions)

Plan Number:                 517

Original Effective Date:     January 1, 1985

Plan Sponsor:                Swedish Health Services
                             747 Broadway
                             Seattle WA 98122
                             206-386-3636

Plan Sponsor’s Employer      91-0433740
Identification Number:

Named Fiduciary:             Swedish Health Services

Plan Administrator:          Swedish Health Services
                             Benefits Department
                             747 Broadway
                             Seattle WA 98122
                             206-386-3636

Plan Trustees:               A list of plan trustees is available upon request from the Plan Administrator

Third Party Administrator:   First Choice Health Network, Inc. d.b.a.
                             First Choice Health Administrators
                             600 University Street, Suite 1400
                             Seattle WA 98101
                             800-750-5202/Local: 206-268-2360
                             www.1stchoiceadmin.com




                                                  64
Agent for Service of Legal   Swedish Health Services:
Process:                     Richard H. Peterson, President & CEO
                             Swedish Health Services
                             747 Broadway
                             Seattle WA 98122

                             FCHA:
                             Gary R. Gannaway, President & CEO
                             First Choice Health Network, Inc.
                             600 University Street, Suite 1400
                             Seattle WA 98101

Plan Document:               The written Plan document required by ERISA §402 consists of this entire
                             document.




                                                 65
Plan Definitions
Accidental injury means physical harm caused by a sudden and unforeseen event at a specific time and
place.

Adverse benefit determination means a denial, decrease or ending of a benefit. This includes a failure to
provide or make payment (in whole or in part) for a benefit including claims based on medical necessity
or experimental and investigational exclusions.

Agreement means the services agreement, attachments and any endorsements or amendments to the
agreement approved by Swedish Health Services and First Choice Health Network, Inc. d.b.a. First
Choice Health Administrators (FCHA.)

Allowed amount means the maximum amount paid by the Plan for a medically necessary covered
service. Generally, this is a contract amount agreed to by FCHN participating providers (known as the
First Choice Health Network). The allowed amount paid by the Plan for services from non-network
providers and for out-of-area providers is based on usual, customary and reasonable (UCR) rates.

Ambulatory surgical facility means a licensed facility used mainly for performing outpatient surgery.

Authorized representative means an individual acting on behalf of the participant or beneficiary
claimant in obtaining or appealing a benefit claim. The authorized representative must have a signed form
(specified by the Plan) by the claimant except for urgent care benefits or appeals. Once an authorized
representative is selected, all information and notifications should be directed to that representative until
the claimant states otherwise.

Baseline means the initial test results to which future results will be compared in order to detect
abnormalities.

Beneficiary is a person designated by the participant or by the terms of a plan who is or may become
entitled to receive a plan benefit.

Birthing center means any freestanding licensed health facility, place, professional office or institution,
that is not a hospital or in a hospital, where births occur in a home-like atmosphere. This facility must be
licensed and operated in accordance with the laws pertaining to birthing centers in the jurisdiction where
the facility is located. It must:

•   Have facilities for obstetrical delivery and short-term recovery after delivery

•   Provide care under the full-time supervision of a physician and either a registered nurse or a licensed
    nurse-midwife

•   Have a written agreement with a hospital in the same locality for immediate acceptance of patients
    who develop complications or require pre- or post-delivery confinement.

Bitewing x-ray means an x-ray that reveals the condition of the top visible part of the upper and lower
molar teeth.




                                                     66
Calendar year means the 12-month period beginning January 1 and ending December 31 of the same
year.

Certificate of creditable coverage means a certificate issued by a group health plan that describes a
person’s prior period(s) of creditable health care coverage as required by the Health Insurance Portability
and Accountability Act of 1996 (HIPAA).

Chemical dependency means an illness characterized by a physiological or psychological dependency,
or both, on a controlled substance and/or alcohol, that impairs or endangers the participant’s or
beneficiary’s health.

Child means an unmarried natural child, adopted child, child placed with the participant for legal
adoption, a stepchild or other legally designated ward up to the dependent child limiting age of 19.
Dependent children who are actively enrolled students or who have charitable activity status have an
extended dependent limiting age of 23.

Claim means any request for a Plan benefit made by you or your authorized representative. A participant
making a claim for benefits is a claimant.

Coinsurance means a cost-sharing requirement that requires a participant to pay a specific percentage of
the cost for certain covered services.

Concurrent claim means any claim that is reconsidered after an initial approval for ongoing treatment
and results in a reduced or terminated benefit.

Custodial care is care designed primarily to assist in activities of daily living, including institutional care
that serves primarily to support self-care and provide room and board. Custodial care includes, but is not
limited to, bathing, dressing, walking assistance, help with getting in and out of bed, feeding, preparing
special diets and supervising medications that are ordinarily self-administered.

Deductible means the amount a participant or beneficiary must pay each calendar year before benefits are
payable from the Plan. Only covered services apply toward the calculation of the annual deductible.

Dental professional means any of the following who is acting within the scope of their license:

•   Doctor of dental medicine (DMD)

•   Doctor of dental surgery (DDS)

•   Dental hygienist

•   Denturist.

Dental services refer to services by any licensed dental provider that are related to natural and unnatural
teeth or structures and tissues contiguous to teeth (whether or not teeth are actually present). Dental
services also include any associated service, such as but not limited to anesthesia, lab, pathology,
supplies, appliances, x-ray or facility support.

Dentist is a person properly trained and licensed to practice dentistry and practicing within the scope of
such license.




                                                      67
Dependent means a participant’s legal spouse or child under age 19 (age 23 for actively enrolled
students) or child the participant primarily supports because they are incapable of self-sustaining
employment due to mental or physical handicap. Dependent children include a legally adopted child or
stepchild who lives with the participant.

Dependent child limiting age is up to 19, or up to 23 if the dependent is an actively enrolled student.

Developmental disability means a condition that meets all of the following:

•   Is defined as mental retardation, cerebral palsy, epilepsy, autism or other neurological or other
    condition

•   Originates before the individual reaches age 18

•   Is expected to continue indefinitely

•   Results in a substantial handicap.

Durable Medical Equipment (DME) is medical equipment that can withstand repeated use, is not
disposable, is used to serve a medically therapeutic purpose, is generally not useful to a person in the
absence of a sickness or injury and is appropriate for use in the home.

Eligible retiree is a class of eligible employees who retired between May 1, 1979 and June 1, 1985.

Emergency means the emergent and acute onset of a symptom or symptoms, including severe pain, that
would lead a prudent person acting reasonably to believe a health condition exists that requires immediate
medical attention, and that failure to provide medical attention would result in serious impairment to
bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s health in
serious jeopardy.

Employer is Swedish Health Services. Swedish Health Services is the Plan Sponsor self-insuring this
group health plan.

Endodontics is a branch of dentistry that deals with the diagnosis and treatment of diseases of the dental
pulp and tissues around the root end.

ERISA is the federal Employee Retirement Income Security Act of 1974, as amended, which governs
plan administration, supervision and management.

Experimental and investigational procedures mean services determined to be:

•   Not in general use in the medical community

•   Not proven safe and effective or to show a demonstrable benefit for a particular illness or disease

•   Under continued scientific testing and research

•   A significant risk to the health or safety of the patient

•   Not proven to result in greater benefits for a particular illness or disease than other generally available
    services.



                                                       68
First Choice Health Administrators (FCHA) is the Third Party Administrator for this group health
plan.

First Choice Health Network, Inc. (FCHN) is the network of providers that is used by FCHA and
defines the service area.

Fiduciary means, under ERISA, a person who exercises discretionary authority or control over the
management of an ERISA plan or its assets or has discretionary authority or responsibility in Plan
administration.

Fluoride is a substance that, when topically applied or added to drinking water, is effective in resisting
tooth decay.

Generic drug is a chemically equivalent copy designed from a brand name drug whose US patent has
expired. Generics are typically less expensive than brand name drugs.

Genetic information means information about genes, gene products and inherited characteristics that
may derive from an individual or a family member. This includes information regarding carrier status and
information derived from lab tests to identify mutations in specific genes or chromosomes, physical
medical exams, family histories and direct analysis of genes or chromosomes.

Home health care agency means an agency that primarily provides skilled nursing service and other
therapeutic service under the supervision of a physician or registered nurse. The home health care agency
provides a home health care plan for the care and treatment of a person in his or her home. Home health
care is not custodial care or the care and treatment of the mentally ill.

Hospice care means a coordinated program to meet the medical, nursing, physical, psychological and
social needs of persons who have a terminal illness.

Incur, incurs, incurred and incurred date mean, with respect to a dental expense, the date the services
or supplies are provided, except:

•   Bridgework, a crown or onlay work is incurred on the date the tooth or teeth are prepared

•   Placement or modification of a full or partial denture is incurred on the date the impression is made

•   Root canal therapy is incurred on the date the pulp chamber is opened.

Initial eligibility means the date an eligible person is first eligible for coverage under this Plan.

Late entrant means, under HIPAA, an individual who enrolls into a group health plan after the first
available enrollment period and who is not a special enrollee with a qualifying event.

Lifetime is a reference to benefit maximums and limitations, understood to mean while covered under
this Plan. Under no circumstances does lifetime mean during the lifetime of the participant.

Medical group means a group or association of providers, including hospital(s), listed in the provider
directory.




                                                      69
Medically necessary is a medical service or supply that meets all the following criteria:

•   It is required for the treatment or diagnosis of a covered medical condition

•   It is the most appropriate supply or level of service that is essential for the diagnosis or treatment of
    the patient’s covered medical condition

•   It is known to be effective in improving health outcomes for the patient’s medical condition in
    accordance with sufficient scientific evidence and professionally recognized standards

•   It is not furnished primarily for the convenience of the patient or provider of services

•   It represents the most economically efficient use of medical services and supplies that may be
    provided safely and effectively to the patient.

The fact that a service or supply is furnished, prescribed or recommended by a physician or other provider
does not, of itself, make it medically necessary. A service or supply may be medically necessary in part
only.

Network provider means a contracted FCHN provider in Washington, Idaho, Montana and Alaska that is
listed in the provider directory. Outside these states, Providence Preferred Network of Oregon or the
Beech Street Network are the preferred provider networks.

Non-network provider means a provider who delivers or furnishes health care services but is not a
contracted FCHN provider in Washington, Idaho, Montana or Alaska. Outside these states a non-network
provider means a provider who delivers or furnishes health care services but is not a contracted
Providence Preferred Network of Oregon or Beech Street Network provider.

Out of area/out of the service area means outside the FCHA service area as described under network
provider and non-network provider.

Participant means any eligible retiree or other eligible individual enrolled in the Plan.

Plan Administrator means the department designated by an employer group to administer a plan on
behalf of participants. For this Plan, Plan Administrator means the Swedish Health Services Benefits
Department (with First Choice Health Administrators as Third Party Administrator). The principal duty of
the Plan Administrator is to see that the Plan is carried out, in accordance with its terms, for the exclusive
benefit of eligible participants and beneficiaries, without discrimination. The Plan Administrator has the
power and exclusive authority necessary, at its discretion, to:

•   Construe and interpret the Swedish Health Services plans and to decide all questions of eligibility and
    participation

•   Make all findings of fact for Plan administration, including payment of reimbursements

•   Prescribe procedures to be followed and forms to be used by participants and beneficiaries

•   Request and receive from all retiree participants the information necessary for proper Plan
    administration




                                                      70
•   Appoint and employ the individuals or entities to assist in Plan administration as necessary or
    advisable, including benefit consultants and legal counsel.

Periodontal splint means any appliance designed to retain teeth in position, and includes multiple
abutments for fixed bridgework.

Periodontics is a branch of dentistry that deals with the prevention and treatment of diseases of the bone
and soft tissues surrounding the teeth.

Plan document means this document, which describes requirements for eligibility and enrollment,
covered services, limitations and exclusions, and other terms and conditions that apply to participation in
this Plan.

Post-service claim means any claim for a Plan benefit that is not a pre-service claim and is a request for
payment or reimbursement for covered services already received.

Pre-certification is the process of obtaining coverage determination from FCHA before receiving
inpatient and certain outpatient services, as specified in the component plans’ benefit description
booklets.

Pre-service claim means any claim for a Plan benefit for which the Plan requires approval before medical
care is obtained.

Prosthetic devices are artificial substitutes that generally replace missing parts of the human body, such
as a limb, bone, joint, eye, tooth or other organ and materials that become ingredients or components of
prostheses.

Prosthodontics is a branch of dentistry that deals with the replacement of missing teeth or oral tissues by
artificial means, such as crowns, bridges and dentures.

Primary Care Provider (PCP) means a general practitioner, internist, family practitioner, general
pediatrician or Advanced Registered Nurse Practitioner (ARNP) chosen by a participant to coordinate all
health care needs.

Provider means any person, organization, health facility or institution licensed to deliver or furnish health
care services.

Provider directory is the listing of the network providers, hospitals, and other facilities that have agreed
to provide covered services to Swedish Health Services participants or dependents.

Qualifying event means, under COBRA, the triggering event that causes a loss of coverage under a group
health plan, including termination of employment, reduction in hours, death or divorce.

Restorative means a process used to replace a lost tooth or part, or the diseased portion of one, by
artificial means as with a filling, crown, bridge or denture designed to restore proper dental function.

Retiree contribution is the retiree’s portion of the costs for this Plan.

Sealants are a resinous material designed for application to the surfaces of posterior teeth in order to seal
the surface irregularities and prevent tooth decay.




                                                      71
Skilled care services may include skilled nursing and skilled rehabilitation services that meet all the
following criteria:

•   Must be delivered or directly supervised by licensed professional medical personnel in order to obtain
    the specific medical outcome

•   Are ordered by a physician

•   Are medically necessary to treat the sickness, injury or medical condition.

Determination of benefits for skilled care services is based on both the skilled nature of the specific
service and the need (medical necessity) for physician-directed medical management. The absence of a
caregiver to perform an unskilled service does not cause the care to become skilled.

Skilled nursing facility means a qualified facility designated by FCHA that has the staff and equipment
to provide skilled nursing care as well as other related services.

Spouse means an individual who is living in a lawfully recognized marital relationship with the
participant.

Temporomandibular Joint (TMJ) Disorders mean disorders that have one or more of the following
characteristics:

•   Pain in the musculature associated with the temporomandibular joint

•   Internal derangement of the temporomandibular joint

•   Arthritic problems with the temporomandibular joint

•   An abnormal range of motion or limited motion of the temporomandibular joint.

Third Party Administrator (TPA) is the organization providing services, as may be delegated, to
Swedish Health Services in connection with operating this Plan, including processing and payment of
claims. FCHA is the Third Party Administrator for this Plan.

Urgent care means services that are medically necessary and immediately required as a result of an
unforeseen illness, injury or condition that is not an emergency, but it was not reasonable given the
circumstances to wait for a routine appointment. Urgent care may be obtained through a provider and is
not limited to the emergency room.

Urgent care claim means a claim for medical care or treatment that, if normal pre-service standards are
applied:

•   Would seriously jeopardize the claimant’s life, health or ability to regain maximum function

•   In the opinion of a physician with knowledge of the claimant’s medical condition, would subject the
    claimant to severe pain that cannot be adequately managed without the care or treatment requested.

Usual, Customary and Reasonable (UCR) is the allowed amount paid by FCHA for medical plan
services received from non-network providers and for dental plan services. This amount is designated by
an independent entity according to the applicable geographic location.



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