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UPS Health Program

                          F O R PA R T - T I M E E M P LOY E E S

S U M M A R Y   P L A N     D E S C R I P T I O N

                                               Schedule 115
                              Central Ohio Locals 20, 40, 908, 957
                                             Indiana Locals 89, 135
                             Kentucky Locals 89 (Center 4210), 957
                             Metro Detroit Locals 20, 164, 243, 339
                    Michigan Locals 7, 328, 332, 339, 406, 486, 580
                                         North Ohio Locals 20, 377
                                       South Illinois Locals 215, 236
UPS
                                                                                                                             HEALTH
Your Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
                                                                                                                           PROGRAM
Who is Covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
                                                                                                                             Schedule
When Coverage Begins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
                                                                                                                                  115
When Coverage Ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Important Information About Plan Expenses . . . . . . . . . . . . . . . . . . . . . . . . . 4

Basic Hospital Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Basic Medical Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Major Medical Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Alternatives to a Hospital Stay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Prescription Drug Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Vision Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Dental Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Life Insurance and AD&D Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Short-term Disability Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Extension of Medical Coverage During Disability . . . . . . . . . . . . . . . . . . . . . . 25

How to File a Claim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

If Your Claim is Denied . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Right of Recovery/Subrogation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Coordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Life Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Continuation of Coverage under COBRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Your Right to Obtain Individual Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

ERISA Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Plan Administration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Since this booklet was last updated, certain changes, required notifications
                                                                                                                                    1
and clarifications have been made to the Plan. You’ll find any notices of
these changes, called Summary of Changes, at the end of this booklet.
Refer to this information when reviewing your coverage.
UPS
HEALTH     Concern for the security and well-being           Your coverage from the Plan is a result
           of you and your family is the cornerstone         of the Company’s agreement with your
PROGRAM    of our benefits philosophy. We regard our         collective bargaining unit. You’ll find
           benefits expenditures as an investment in         specific reference to the coverage in
           your health and security. The UPS Health          your labor agreement.
Schedule   Program (the Plan) provides health benefits
115        to help pay for the cost of your health care.
           The Plan also protects you and your family        WHO IS COVERED
           with life insurance, accidental death and
           dismemberment and short-term disability           As a part-time bargaining unit employee
           income coverage. UPS pays the full cost           of UPS, you and your qualified dependents
           of the benefits described in this booklet.        are covered once you meet the Plan’s eligi-
                                                             bility requirements as described in the “When
                                                             Coverage Begins” section of this booklet.
           YOUR PLAN
                                                             An “eligible dependent” is defined as:
           As an employee of United Parcel Service,            • Your legal spouse
           you’re eligible for benefits from the Plan          • An unmarried child who is:
           once you’ve met the eligibility require-               —A natural child, an adopted child,
           ments. There may be a waiting period for                 a stepchild or a child for whom you
           certain coverage for you or for your depen-              are the legal guardian or custodian
           dents. Please see “When Coverage Begins”                 and who depends on you for finan-
           in this booklet for eligibility requirements             cial support and lives with you in
           you and/or your dependents must meet                     a parent-child relationship, and
           before you receive benefits from this Plan.
                                                               —Under age 19, or up to age 25 if a
           The UPS Health Program Schedule 115                    full-time student and still financially
           covers part-time union member employees                dependent on you.
           in the following work groups:
                                                             Incapacitated Children
              • Central Ohio Locals 20, 40, 908, 957         A child who becomes incapacitated
              • Indiana Locals 89, 135                       before age 19 (or before age 25, if a full-
              • Kentucky Locals 89                           time student) will continue to have medical
                (Center 4210), 957                           coverage as long as the incapacitation
              • Metro Detroit Locals 20, 164,                exists and you remain eligible for the Plan.
                243, 339                                     This continuing coverage is available as
              • Michigan Locals 7, 328, 332, 339,            long as the child becomes incapacitated
                406, 486, 580                                while covered by the Plan, is unmarried
                                                             and primarily dependent on you for support
              • North Ohio Locals 20, 377
                                                             and maintenance. Dependent life insurance
              • South Illinois Locals 215, 236               continues through the end of the year in
                                                             which your child turns 19 (or age 25 if
           Other benefit schedules have been prepared
                                                             a full-time student).
           describing this Plan as it applies to employees
           in other employment groups. Please be cer-
           tain you have the proper information for
           your employment group.

2
UPS
Your child must have a mental or physical        Qualified Medical Child Support Orders           HEALTH
incapacity that renders the child unable to      (QMCSO)
care for herself/himself, as determined by       Medical, dental and vision coverage will       PROGRAM
the claims administrator. For this purpose,      comply with the terms of a Qualified
the incapacity must be verified before cov-      Medical Child Support Order. A QMCSO
erage can be continued. In addition, periodic    is a judgment, decree or order (including        Schedule
medical documentation of the continuing          approval of settlement agreement) issued              115
incapacity is required.                          by a court of competent jurisdiction or an
                                                 administrative process established under
When Spouses or Children Are UPSers              state law which has the force and effect
If you and your spouse both work for             of law or a judgment from a state court
UPS and are both covered through a UPS-          directing a plan administrator to cover a
administered plan, you may not cover your        child by a company’s group health plans.
spouse as a dependent in the Health Program.
Your dependent children can have health care     Federal law requires that a QMCSO must
coverage as one parent’s dependent only.         meet certain form and content requirements
                                                 in order to be valid. When an order is
If you and your dependent child both             received, each affected participant and each
work for UPS and are both covered through        child covered by the order will be notified
a UPS-administered plan, you cannot              of the implementation procedure to deter-
cover your child as a dependent in the           mine if the order is valid. If you have any
Health Program.                                  questions or would like to receive a copy
                                                 of the UPS written procedure for determin-
There is no coordination of benefits avail-      ing whether a QMCSO is valid, please con-
able between two UPS-administered plans.         tact your Human Resources department.

WHEN COVERAGE BEGINS
Eligibility for medical, life and accidental
death and dismemberment (AD&D) cover-
age for you and your dependents begins
on the first day of the month following
one full month of employment, provided
you have attained seniority. If you have not
attained seniority at this time, coverage will
begin on your seniority attainment date.

Eligibility for vision and dental coverage
begins six months from your hire date,
provided you have attained seniority.

A definition of seniority can be found
in your collective bargaining agreement.

                                                                                                         3
UPS
HEALTH     WHEN COVERAGE ENDS                            IMPORTANT INFORMATION
PROGRAM    For You...
                                                         ABOUT PLAN EXPENSES
             • Coverage ends 31 calendar days            All expenses covered by this Plan must be:
               after you leave UPS
Schedule     • The end of the second month
                                                            • Medically necessary, as determined
                                                              by the claims administrator, Aetna
115            of a layoff period                           • Neither investigational nor experi-
             • The day you start a personal leave that        mental, as determined by the
               is not covered by the Family Medical           claims administrator
               Leave Act                                    • Within the standards for the reasonable
                                                              and customary amount, as determined
           For Your Spouse...
                                                              by the claims administrator
           The earliest of:
                                                            • Not excluded by the Plan
             • The date your coverage ends
             • The date you and your spouse              Medically Necessary
               are divorced                              Services and Supplies
             • The date you and your spouse              Only medically necessary services are
               are legally separated                     covered by the UPS Health Program. A
                                                         service or supply is medically necessary
           For Your Dependent Children...                if the Plan determines that it is required
           The earliest of:                              for the diagnosis, care or treatment of a
             • The date your coverage ends               disease, injury or pregnancy in accordance
             • The end of the calendar year in which     with generally accepted medical practice.
               your dependent turns 19                   This determination is at the sole discretion
                                                         of the Plan Administrator.
             • The end of the calendar year in which
               your dependent turns 25, provided he      To be medically necessary, the service
               or she is a full-time student             or supply must be:
             • The date your dependent marries or           • Care or treatment that is as likely to
               otherwise fails to meet the require-           produce as significant a positive out-
               ments of an eligible dependent as              come (and no more likely to produce
               described in the “Who is Covered”              a negative outcome) as any alternative
               section                                        service or supply, with respect both to
                                                              the disease or injury involved and to
           See the “Continuation of Coverage During
                                                              the person’s overall health condition,
           Disability” section for information on
                                                              or
           extension of coverage for you and your
           dependents during a disability period.           • A diagnostic procedure, indicated by
                                                              the health status of the person, that is
           There is also important information                as likely to result in information that
           about the Consolidated Omnibus Budget              could affect the course of treatment as
           Reconciliation Act (COBRA), the Family             (and no more likely to produce a nega-
           Medical Leave Act (FMLA) and conver-               tive outcome than) any alternative
           sion privileges in later sections of this          service or supply, with respect to both
           booklet. These provisions may extend               the disease or injury involved and the
           the date on which coverage will end.               person’s overall health condition, and

4
UPS
   • As to diagnosis, care and treatment,          • Dressings, splints and plaster casts         HEALTH
     no more costly (taking into account           • Inpatient laboratory and X-ray
     all health care expenses incurred in            examinations                               PROGRAM
     connection with the service or supply)        • Physical therapy
     than any alternative service or supply
     that meets the above tests
                                                   • Electrocardiograms                           Schedule
                                                   • Oxygen and anesthesia and their
Reasonable and Customary Charges                     administration                                    115
A reasonable and customary (R&C) charge            • The cost and administration of blood
is the lower of either the provider’s usual          and blood-plasma
charge or the prevailing fee for a medical         • Intravenous injections and solutions
service or supply in your geographic area          • X-ray and radium therapy
as determined by the claims administrator.         • Prescribed drugs
If you’re charged more than what is con-
sidered reasonable and customary, you’ll         Outpatient Hospital Services
be responsible for paying anything over the      The following outpatient hospital services
R&C amount. R&C charges are regularly            are also covered in full under the basic
reviewed to keep Plan benefits up-to-date        portion of your Plan:
with current rates.                                 • Pre-surgical testing within seven days
                                                      of a scheduled inpatient admission or
                                                      a scheduled ambulatory surgery
BASIC HOSPITAL COVERAGE                               procedure
Room and Board                                      • Chemotherapy infusion
You and your eligible dependents receive            • Kidney dialysis performed either
full coverage for reasonable and customary            in the hospital or in your home
room and board charges and for other related        • Hospital charges connected with
services and supplies during a medically              outpatient surgery
necessary confinement in a full-service acute       • Hospital emergency room treatment
care or specialty hospital. If you choose to          of a diagnosed life-threatening sudden
stay in a private room, you’re responsible            and serious illness, if care is given
for the difference between the actual semi-           within 72 hours after the injury occurs
private room charge and the private room rate.        or after the illness begins

Inpatient Hospital Services
Your Plan pays full reasonable and customary
charges for these other inpatient hospital
services as long as they are medically nec-
essary to treat the condition requiring hos-
pitalization and are billed by the hospital:
   • The use of operating, recovery and
     treatment rooms and their equipment
   • The use of intensive care and cardiac
     care units

                                                                                                         5
UPS
HEALTH     BASIC MEDICAL COVERAGE                          For benefits to be paid, emergency care
                                                           must be given within 72 hours of an acci-
PROGRAM    Basic Surgical Coverage                         dental injury or the onset of a diagnosed
           Basic surgical coverage pays 100 percent        sudden and serious illness.
           of the reasonable and customary charges
Schedule   of a surgeon and assistant surgeon (when        Physician Charges for Hospital Visits
                                                           Often when you or your covered depen-
115        required) including anesthesia for the pro-
                                                           dents are hospitalized, your physician will
           cedure. You do not need to pay a deductible
           before the Plan pays benefits.                  treat you in the hospital. These charges are
                                                           covered up to $20 per day.
           For benefit purposes, usual, necessary and
           related pre-operative and post-operative        The total amount payable for all treatments
           care is considered part of the surgery. Post-   during one period of continuous disability
           operative care must be given during the         is $7,300 per individual. If you incur charges
           14 days after surgery.                          over the amounts payable under this por-
                                                           tion of your coverage, they will qualify for
           Other surgical procedures are covered           coverage under the major medical portion
           by the Plan, including functional repair        of the Plan.
           of birth abnormalities or congenital defects;
           oral surgery, including the removal of          See the section “What’s Not Covered by
           impacted and wisdom teeth, and tubal            Your Plan” for information on expenses
           ligations or vasectomies.                       excluded from this coverage.

           Diagnostic Procedures                           Mastectomy Coverage
           Outpatient diagnostic X-rays and laboratory     A participant or eligible dependent receiv-
           procedures are also covered up to the R&C       ing benefits for a medically necessary mas-
           amount, including medically necessary           tectomy will also receive coverage for:
           ultrasounds and dental X-rays in connec-           • Reconstruction of the breast on which
           tion with an injury. Up to $300 can be paid          the mastectomy has been performed,
           in benefits for each person each calendar          • Surgery and reconstruction of the
           year. The major medical portion of the               other breast to produce a symmetrical
           Plan covers charges above $300.                      appearance, and
                                                              • Prostheses and treatment of physical
           In addition, radiologists’ and pathologists’         complications of all stages of mastec-
           charges for services given while you                 tomy, including lymphedemas.
           (or a dependent) are hospitalized are
           also covered by the basic medical portion
           of the Plan.

           Emergency Care Physician
           Emergency care given by a physician is
           covered in full up to R&C charges. The care
           may be given in a clinic, doctor’s office or
           the outpatient department of a hospital.

6
UPS
MAJOR MEDICAL COVERAGE                           In calculating your out-of-pocket expenses,        HEALTH
                                                 the dollar amounts included are the deductible
After you pay a yearly deductible, your          and the coinsurance amount. Dollar amounts       PROGRAM
major medical coverage pays 80 percent           not included in determining the out-of-pocket
of most medical expenses not covered by          maximum are any amounts over reasonable
the basic portion of the Plan.                   and customary and expenses that are not            Schedule
                                                 covered by the Plan.                                    115
Yearly Deductible
You’re responsible for paying a major med-       Lifetime Maximum Benefits
ical deductible each calendar year. There        Up to $500,000 in lifetime medical benefits
are individual deductibles and a maximum         can be paid for each person covered by the
family deductible.                               Plan. The maximum is a combined amount
                                                 that is the total benefits paid to you.
The individual deductible is the first $50
of covered major medical expenses. The           Each January 1, up to $1,000 in individual
maximum family deductible is $100. This          benefits paid during the preceding year or
means that if two or more family members         years will automatically be restored. If
have combined covered expenses of $100,          proof of your (or your dependent’s) good
no further individual deductibles are required   health is approved by Aetna, the $500,000
for the balance of that year.                    major medical maximum can be fully restored.

Coinsurance                                      Covered Major Medical Expenses
After the deductible has been met,               The following is a general listing of cov-
the Plan pays 80 percent of the reasonable       ered expenses under the major medical
and customary charges for covered major          portion of your Plan:
medical expenses. You pay the remaining             • Reasonable and customary charges
20 percent.                                           of a physician, including an osteopath,
                                                      chiropractor or podiatrist for medically
Out-of-Pocket Maximum                                 necessary treatment
There is an important provision of your             • Second surgical opinions
major medical coverage that assures you
                                                    • Charges of a social worker. In order
that your yearly out-of-pocket expenses for
                                                      for expenses to be covered, the social
covered major medical charges will never
                                                      worker must be either a licensed clini-
be more than a certain dollar amount. This
                                                      cal social worker, a diplomate social
feature can be particularly valuable if you
                                                      worker or a member of the Academy
(or a dependent) have a catastrophic illness
                                                      of Credited Social Workers and licensed
or injury.
                                                      in the state where he or she practices.
After you meet the out-of-pocket maxi-              • Charges of a registered graduate nurse
mum of $1,500 per individual each year,               (RN), licensed vocational nurse (LVN)
100 percent of most covered charges are               or licensed practical nurse (LPN)
paid for that individual for the rest of the        • Some charges relating to care of mental
calendar year.                                        or nervous disorders, chronic alcoholism
                                                      or drug addiction (See the “Mental
                                                      Health Treatment,” and “Substance
                                                      Abuse” sections.)

                                                                                                           7
UPS
HEALTH     • Charges for home health care (See the      Maternity
             “Home Health Care” section.)               Maternity expenses are covered just like any
PROGRAM    • Charges for hearing exams and an           other condition requiring medical attention.
             initial hearing aid. To be covered,
             the hearing aid must be recommended        Your medical coverage for pregnancy and
Schedule     by an otolaryngologist. Eyeglass-type      delivery includes full hospital and surgical
                                                        benefits. Charges for hospital and diagnos-
115          hearing aids are covered up to the cost
                                                        tic services are covered as described in
             of one traditional hearing aid. Replace-
             ment or repair of a lost, broken or        earlier sections.
             stolen aid is not covered.
                                                        Basic surgical coverage pays the cost of
           • Outpatient physical therapy and occu-      Lamaze or other birthing classes. It also
             pational therapy subject to review and     pays full surgical benefits for delivery in
             approval by the claims administrator       a licensed birthing center, including anes-
           • Charges for speech therapy, depending      thesia and pre- and post-operative care.
             on the diagnosis and subject to review     Obstetrical procedures that are fully cov-
             and approval by the claims administra-     ered include normal delivery or delivery
             tor (See “Speech Therapy” section.)        by cesarean section, services in connection
           • Charges for vision therapy, depending on   with a miscarriage or abortion, and surgery
             the diagnosis and subject to review and    related to an extrauterine or ectopic preg-
             approval by the claims administrator       nancy. The services of a registered midwife
           • Charges for medically necessary            are also covered.
             ambulance services to the nearest
             facility for appropriate treatment         The Plan assumes you (or your dependent)
             of the condition                           will have only one primary obstetrician
           • Charges for diagnostic X-rays and lab-     during a single pregnancy. Typically, an
             oratory exams that are over the $300       obstetrician establishes a fee for the entire
             paid for by basic medical coverage         period of care. If you change doctors and
                                                        the second doctor’s charges are in addition
           • Charges for radioactive therapy
                                                        to the first doctor’s fee, only one R&C
           • Charges for outpatient or home             amount will be covered by the Plan.
             chemotherapy
           • Charges for the rental (or purchase,       The procedure for filing claims is described
             if medically necessary) of durable         in the section “Filing a Claim.” As you
             medical or surgical equipment              read that section, keep in mind you may
           • Charges for allergy syringes               submit your bills for maternity care on
             and serums                                 an ongoing basis. You do not need to wait
                                                        until the pregnancy is completed. However,
                                                        full maternity benefit payment will not be
                                                        made until completion of the pregnancy.

8
UPS
Newborns’ and Mothers’ Health                     Outpatient Treatment                                HEALTH
Protection Act                                    Outpatient mental health treatment is covered
Group health plans and health insurance           as long as the treatment is recommended           PROGRAM
issuers generally may not, under federal          by a doctor, is considered medically neces-
law, restrict benefits for any hospital length    sary and appropriate for the condition, and
of stay in connection with childbirth for the     meets the other requirements noted above.           Schedule
mother or newborn child to less than 48           Benefits are payable at 80 percent after the
                                                  yearly deductible is met.
                                                                                                           115
hours following a vaginal delivery, or less
than 96 hours following a cesarean section.
                                                  When Benefits Are Not Payable
However, federal law generally does not           No benefits are payable for charges of
prohibit the mother’s or newborn’s attend-        a residential treatment facility or for educa-
ing provider, after consulting with the mother,   tional services.
from discharging the mother or her new-
born earlier than 48 hours (or 96 hours, as       Before you begin treatment that requires any
applicable). In any case, plans and issuers       services not specifically identified as covered
may not, under federal law, require that a        services for mental or nervous disorders, you
provider obtain authorization from the plan       should contact the claims administrator to
or the issuer for prescribing a length of stay    see if benefits are payable.
not in excess of 48 hours (or 96 hours).
                                                  Substance Abuse
                                                  Substance abuse can create difficult problems
Mental Health Treatment                           not only for the person who abuses the
Mental health treatment is covered as long        substance, but also for all family members.
as a doctor recommends treatment and the          If you would like a referral for yourself
Plan administrator determines it to be med-       or your spouse or a dependent dealing with
ically necessary.                                 a substance abuse problem, please see your
                                                  district Human Resources department, which
The treatment must be given by a psychia-         will refer you to your Employee Assistance
trist or by a licensed or certified psycholo-     Program (EAP) coordinator. Discussions
gist. Care given by a social worker will be       between you and the EAP coordinator will
covered as long as he or she meets the cri-       be confidential within the limits of legal
teria listed in the “Covered Major Medical        and professional constraints.
Expenses” section. Major medical benefits
for mental health treatment apply toward the      Major medical benefits for these services
$500,000 lifetime benefit maximum.                apply toward the $500,000 benefit maximum.
                                                  Psychological counseling by a psychiatrist,
Inpatient Treatment                               licensed or certified psychologist, or a
Inpatient mental health treatment is              social worker is covered. The social worker
covered the same as any other condition           must meet the criteria specified in the
requiring hospitalization. The treatment          “Covered Major Medical Expenses” section.
must be recommended by a doctor and be
considered medically necessary and appro-
priate for the condition. Major medical
coverage is available for partial confinement
in an approved day/night-care facility.

                                                                                                             9
UPS
HEALTH     Inpatient Treatment                             services for all children between the ages
           Inpatient treatment for substance abuse         of three and 21, including help in identify-
PROGRAM    is covered the same as any other condition      ing and diagnosing speech and language
           requiring hospitalization. Major medical        disorders as well as rehabilitative and
           coverage is available for partial confine-      preventative treatment. As a result, treat-
Schedule   ment in an approved day/night-care facility.    ment of these kinds of speech problems
115        Outpatient Treatment
                                                           is not covered.

           As long as the treatment is recommended         To be eligible for benefits, treatment
           by a doctor and meets the other require-        of a speech problem must be prescribed,
           ments noted above, benefits are payable         controlled and directed by a doctor and
           at 80 percent of covered expenses.              approved by the claims administrator.

           When Benefits Are Not Payable                   Besides the exclusions noted in the section
           No benefits are payable for care given          “What’s Not Covered by Your Medical
           in a halfway house or residential treat-        Benefits” and situations covered by Public
           ment facility.                                  Law 94-142, there are other conditions and
                                                           services not covered by the medical portion
           Speech Therapy                                  of the Plan. These include:
           Benefits are paid only for speech therapy          • Certain speech problems in children
           needed to restore speech lost as a result of         that are classified as developmental
           an illness or injury. For example, children          delays that may correct themselves
           who have not fully developed their speech            without treatment
           skills are not eligible for these restorative
                                                              • Services rendered for the treatment
           services. However, someone who loses
                                                                of delays in speech development, unless
           speech capacity as a result of an accident
                                                                resulting from injury or illness
           could receive benefits under this provision.
                                                              • Speech problems caused by learning
           Speech problems can be unique, varying               disabilities or articulation disorders
           in severity from individual to individual,           (if there is an underlying psychological
           and frequently, diagnoses can be subjec-             reason for the condition, that underly-
           tive. To help determine if the condition             ing condition may be covered as a
           is covered by the Plan, submit information           mental or nervous disorder)
           to the claims administrator for advance            • Services or supplies that a school
           review. This way, you’ll know what bene-             system is required by law to provide
           fits can be paid before treatment begins.          • Services of a speech therapist who
                                                                lives in your home
           Certain speech problems, such as stuttering
                                                              • Special education, including lessons in
           in children, may be covered by Public Law
                                                                sign language, to teach a covered person
           92-142, The Education for All Handicapped
                                                                whose ability to speak has been lost or
           Children Act of 1975. This law provides
                                                                impaired to function without that ability
           public schools with language and speech

10
UPS
ALTERNATIVES TO                                   The following expenses are not covered             HEALTH
                                                  by home health care:
A HOSPITAL STAY                                      • Services or supplies not included           PROGRAM
Rather than a stay as a hospital inpatient,            in the home health care plan outlined
                                                       by your physician
an alternative course of medical care may
                                                     • Services of a person who ordinarily
                                                                                                     Schedule
be more appropriate, cost effective and
comfortable. Expenses are covered for the              lives in your home or who is a member              115
following alternatives to a hospital stay.             of your or your spouse’s family
                                                     • Custodial care
Home Health Care                                     • Transportation
Charges made by a home health agency
for a covered family member in the home           Outpatient Private Duty Nursing
in accordance with a home health care plan        Benefits may be paid for medically skilled
are covered by this benefit. For these expenses   private duty nursing at home if your doctor
to be eligible, the home health care plan         prescribes it. Benefits cover the home ser-
must be outlined by your physician.               vices of registered nurses, licensed practical
                                                  nurses and licensed vocational nurses up to
After the deductible, benefits are paid           a maximum of 560 hours per calendar year
at 80 percent of reasonable and customary         (70 eight-hour shifts). The 560 hours are
charges.                                          counted as they are used. For example,
                                                  a two-hour visit will be counted as two
Covered home health care expenses include:        hours, rather than an eight hour shift.
  • Part-time or intermittent home health
    aide services, consisting primarily of        To be covered, outpatient private duty
    caring for the patient in conjunction         nursing services must:
    with skilled nursing care                       • Be medically necessary for treatment
  • Physical, occupational or speech therapy          of a disease or injury
  • Drugs and most medical supplies                 • Require the medical training and
    prescribed by a physician                         technical skills of a registered nurse,
  • Laboratory services                               licensed practical nurse or licensed
                                                      vocational nurse, and
Home health care benefits are calculated            • Be ordered by the attending physician
on a per-visit basis. Each visit by a nurse,          as necessary treatment
therapist or aide is considered one visit;
four hours is the maximum length of one           The charges of a private duty nurse in a
visit. Up to 120 home health care visits per      hospital are not covered because the hospital
Plan year are covered. For the first 40 vis-      provides a staff of registered nurses for care
its, the patient does not need to have been       given during hospitalization. These charges
confined in a hospital in order to be eligi-      are part of the room and board charges.
ble for benefits. For an additional 80 visits,
prior hospital confinement is required, and       Skilled nursing care is not the same as
the home health care must begin within            custodial care. Custodial care is not cov-
seven days following discharge.                   ered even if given by an RN, LPN or LVN.
                                                  Custodial care includes such things as meal

                                                                                                            11
UPS
HEALTH     preparation, bathing the patient, acting as      The following services and supplies
           a companion and other services that may          are allowable when furnished to a person
PROGRAM    be necessary for the normal activities of        receiving outpatient hospice care coordinated
           daily living, but that do not require the med-   by the hospice program administrator:
           ical training and technical skills of a nurse.      • Part-time intermittent nursing care
Schedule   Daily nursing notes will be reviewed to               by an RN or LPN for up to eight hours
115        determine the portion of the nursing care             in any one day
           that qualifies for benefits.                        • Medical social services under the
                                                                 direction of a physician, including:
           It’s also important to understand that while
           skilled nursing care may be necessary ini-             —Assessment of the person’s social,
           tially, alternate caregivers may be encouraged            emotional and medical needs and/
           to learn the skills necessary for ongoing                 or the home and family situation
           medical care. Once alternate caregivers                —Identification of community
           have demonstrated their proficiency in                    resources needed to meet her
           a particular procedure, skilled nursing                   or his assessed needs
           coverage for that procedure may cease.                 —Assistance with obtaining the
                                                                     resources needed to meet her
           No benefits will be paid for services given               or his assessed needs
           by a nurse who lives with you.                      • Psychological and dietary counseling
                                                               • Consultation or case management
           Call the toll-free number on your medical
                                                                 services by a physician or nurse
           identification card before you make any
           arrangements for outpatient private                 • Physical therapy
           duty nursing.                                       • Part-time or intermittent home health
                                                                 aid services for up to eight hours in
           Hospice Care                                          any one day. These consist mainly
           Hospice care provides terminally ill patients         of caring for the person.
           and their families with an alternative to hos-
           pital care while assuring them of a special-     Benefits are not provided for the following
           ized program tailored to each individual.        hospice care services and supplies:
           Terminally ill patients require specialized        • Any charge for daily room and board
           care, both medical and psychological, that           in a private room in excess of the insti-
           may not be readily available from the regu-          tution’s semiprivate room rate
           lar hospital staff.                                • Charges made for the following services:
                                                                 —Bereavement counseling
           For purposes of this program, a terminally
           ill patient has a medical prognosis of six            —Funeral arrangements
           months or less to live.                               —Pastoral counseling
                                                                 —Financial or legal counseling,
           Charges for room and board made by                       including estate planning or
           a hospice facility, hospital, convalescent               the drafting of a will
           facility or a physician are allowable when            —Homemaker or caregiver services
           furnished on a full-time inpatient basis for             that are not solely related to care
           pain control and other acute and chronic                 of the person (sitter or companion
           symptom management.                                      services for the patient or other mem-
                                                                    bers of the family, transportation,
                                                                    housecleaning and maintenance
                                                                    of the house)
                                                                 —Respite care
12
UPS
Individual Case Management                     • Services or supplies that are not med-        HEALTH
While none of us likes to think about a          ically necessary, as determined by the
complicated, long-term illness or serious        claims administrator, even if prescribed,   PROGRAM
accident, sometimes it can happen.               recommended or approved by the
                                                 attending physician or dentist
The Individual Case Management (ICM)           • Care, treatment, services or supplies         Schedule
program can offer you and your dependents
help with:
                                                 provided by an individual who usually              115
                                                 resides in the same household with
   • Understanding treatment plans               you, or who is related by blood,
     and alternatives                            marriage or legal adoption to you
   • Monitoring claims payments, and             or your dependent
   • Evaluating alternative treatment          • Services or supplies the claims admin-
     facilities and options                      istrator determines to be unnecessary
                                                 for the diagnosis, care or treatment
Here are some medical conditions that may        of the condition involved
be appropriate for ICM:                        • Care, treatment or services or supplies
   • Quadriplegia, paraplegia                    not prescribed, recommended and
   • AIDS and certain associated symptoms        approved by the attending physician
   • Brain injury, including traumatic         • Hospital care for diagnostic purposes
     brain injury                                unless the covered person’s condition
   • Newborn respiratory distress,               or type of test requires hospitalization
     newborn apnea                             • Services or supplies not provided
   • Spinal cord injury                          in accordance with medical or profes-
                                                 sional standards of practice
   • Any complicated, chronic illness
                                               • Treatments or procedures and related
If this type of care is appropriate for your     materials that are investigational or
situation, a nurse consultant contacts your      experimental in nature, as determined
doctor or social worker at the hospital to       by the claims administrator
begin case management. You may also call       • Occupational conditions, ailments or
Member Services at the number on your ID         injuries for which coverage is provided
card to discuss whether case management          by Workers’ Compensation or by
is appropriate for your situation. Early         a similar law
identification allows the patient, family,     • Additional expenses for a private room
physician, social worker and case manager        in a hospital
to work together to arrange appropriate        • Private duty nursing while confined
care in a timely manner.                       • Custodial care, rest centers, nursing
                                                 homes or assisted living centers
What’s Not Covered By Your                     • Treatment of a condition caused by
Medical Benefits                                 war (declared or undeclared) or any
The following is a general list of Plan          act of war
exclusions:                                    • Items listed in other sections as not-
   • Charges that exceed the reasonable          covered expenses
     and customary limit, as determined
     by the claims administrator

                                                                                                      13
UPS
HEALTH     • Treatment of a condition incurred              • Claims that the Plan is not required
             while committing an unlawful act of              to pay under the current collective
PROGRAM      aggression, including a misdemeanor              bargaining agreement
             or a felony                                    • Contraceptive medications and devices,
           • Services or supplies for which benefits          regardless of medical necessity
Schedule     are provided by any government law
115        • Services or supplies that are provided
             by reason of past or present service         PRESCRIPTION DRUG
             in the armed forces of any government        BENEFITS
           • Services provided before coverage
             becomes effective or after coverage          Your medical coverage provides prescrip-
             ends                                         tion drug benefits. The reasonable and cus-
           • Dietary supplements, including any           tomary cost (as determined by the claims
             supplement for newborn infants               administrator) of prescription drugs is cov-
           • Any preventive or routine care               ered at 100 percent.
           • Services or supplies related to any eye      Prescription drug benefits are administered
             surgery mainly to correct refractive         by Aetna. You pay for the full amount of
             errors                                       each prescription and submit a completed
           • Services or supplies for or related to       claim form to be reimbursed. Claim forms
             sex change surgery or any treatment          may be obtained from your local Human
             of gender identity disorders                 Resources department or by calling the
           • Reversal of a sterilization procedure        Member Services number on your Aetna
           • Expenses related to the purchase of          ID card.
             orthopedic shoes or related corrective
             devices and appliances                       Prescription drug benefits cover:
           • Personal hygiene or convenience                 • Drugs approved by the federal
             items, such as air conditioners, humid-           government
             ifiers and physical fitness equipment           • State-restricted drugs
           • Items to accommodate your home,                 • Insulin—by prescription only
             office or vehicle as a result of an injury      • Insulin needles, syringes and chem
             or illness, such as wheelchair lifts,             strips—by prescription only
             hand rails or stair risers                      • Over-the-counter diabetic supplies
           • Weight reduction programs, unless               • Compounded medications
             approved by the claims administrator
           • Charges for a missed or broken               Prescription drug benefits do not cover:
             appointment                                     • Contraceptive medications unless
           • Charges for the doctor’s travel                   medically necessary
           • Claims received more than 24 months             • Contraceptive devices
             from the date of service                        • Drugs not approved by the federal
           • Charges for or related to services,               government
             treatment, educational testing or train-        • Drugs used for cosmetic purposes
             ing related to learning disabilities or         • Viagra
             developmental delays                            • Therapeutic devices or appliances

14
UPS
   • Drugs labeled “Caution—limited             Replacement lenses are covered once every          HEALTH
     by federal law to investigational use,”    12 months if required because of a change
     or experimental drugs, even though         in prescription. Replacement frames are          PROGRAM
     a charge is made to the individual         covered after the first prescription is filled
   • Medication for which the cost is           only if the existing frames cannot be used
     recoverable by Workers’ Compensation,      for a new pair of lenses that are prescribed       Schedule
     occupational disease law, any state or     at a later date.                                        115
     governmental agency, or medication
     furnished by any other drug or medical     When Benefits Are Not Payable
     service for which no charge is made        Beside the general medical exclusions
     to the participant                         noted earlier in this booklet, your vision
                                                benefit does not cover the following:
   • Any prescription refilled in excess
     of the number of refills specified by         • Visual analysis that does not include
     the physician, or any refill dispensed          a complete eye refraction
     after one year from the physician’s           • Frames or lenses costing more than
     original order                                  the Plan allows
   • Dietary supplements, including any            • Tinted or photochromatic lenses,
     supplement for newborn infants                  except for pink tints 1 and 2
   • Growth hormones without prior                 • Coated lenses
     authorization                                 • Contact lenses (except as described)
   • Over-the-counter medications (other           • Multifocal plastic lenses
     than diabetic supplies)                       • No-line, blended bifocal lenses
                                                   • Orthoptics or vision training
                                                   • Subnormal vision aids
VISION BENEFITS
                                                   • Aniseikonic lenses
You and your eligible dependents are eligi-        • Two pair of glasses instead of bifocals
ble for one complete eye examination and,          • Replacement of lost or broken lenses
if your prescription changes, one pair of            or frames
new single-vision, bifocal or trifocal eye-        • Medical or surgical treatment of eyes
glasses every 12 months. The eye exam              • Services or materials provided as a
is covered up to reasonable and customary            result of Workers’ Compensation or
limits, as determined by Aetna, the claims           similar legislation or provided through
administrator. Eyeglasses, including lenses          a government agency or program
and frames, are covered according to the
                                                   • Duplicate or spare glasses
following schedule:
                                                   • Eye exams, glasses or contacts provided
Lenses (per pair)                                    by any other vision care plan
        Single vision         $30                  • Vision care services, materials or
        Bifocal               $40                    procedures covered by other provi-
        Trifocal              $50                    sions of the UPS Health Program.
                                                     For example, vision therapy after
Frames                        $30                    cataract surgery is covered by your
                                                     medical benefits.
If for cosmetic reasons you choose contact
lenses in lieu of glasses, the Plan will pay
up to the scheduled benefit for single-vision
lenses and frames ($60).

                                                                                                          15
UPS
HEALTH     DENTAL BENEFITS                                  Preventative Services
                                                            These services are covered in full:
PROGRAM    Services performed by a legally qualified          • Oral exams (once every six months)
           dentist and dental hygienist are covered.          • Prophylaxis (once every six months)
Schedule   Deductible
                                                              • Topical fluoride applications for
                                                                children until the end of the year
115        Basic and major restorative services
                                                                in which the child turns 15 (once
           are subject to the Plan’s major medical
                                                                every six months)
           deductible. The deductible does not apply
           to preventative services or orthodontia. See       • X-rays
           the section titled “Major Medical” for more           —Full-mouth or panoramic
           information about the deductible.                       (once every 36 months)
                                                                 —Bitewing (once every six months)
           Reasonable and Customary                           • Sealants for children until the end of
           All eligible dental expenses are subject to          the year in which the child turns 14
           reasonable and customary limits—charges               —One application per tooth per
           within the normal range of fees in your                 36-month period
           geographic area for similar services and
                                                                 —Permanent first and second
           similar supplies, as determined by the claims
                                                                   molars only
           administrator. If your dentist charges more
           than the R&C limit, you’re required to pay
           any amounts considered above that limit.

           Predetermination of Benefits
           The Plan has a provision that lets you know,
           in advance, what benefits will be paid. If
           you anticipate that charges for a course
           of dental treatment will be more than $300,
           you should submit an itemization of the
           proposed treatment (including recent pre-
           treatment X-rays) to the claims adminis-
           trator before work begins. A dental consultant
           will review the proposed treatment, and the
           administrator will inform you and your den-
           tist of the amount of covered charges. This
           way, you’ll understand the benefits that will
           be paid and have the opportunity to discuss
           possible treatment options with your dentist
           before treatment begins. While predetermi-
           nation is not required, unless it’s an emer-
           gency, you may not wish to begin a course
           of treatment until you know what amount
           the Plan will pay.

16
UPS
Basic Services                                    —Other surgical procedures                    HEALTH
These services are covered at 80 percent            
                                                       Sialolithotomy—removal
after the Plan deductible has been met:               of salivary calculus                    PROGRAM
   • Visits and exams                               
                                                       Closure of salivary fistula
      —Professional visit after hours
      —Consultation by a specialist
                                                    
                                                       Dilation of salivary duct                Schedule
                                                    
                                                      Transplantation of tooth or tooth bud
      —Emergency palliative treatment               
                                                       Removal of foreign body from
                                                                                                     115
   • X-ray and pathology                              bone (independent procedure)
      —Single films (up to 13)                      
                                                       Maxillary sinusotomy for removal
      —Intra-oral, occlusal view, maxillary           of tooth fragment or foreign body
         or mandibular                              
                                                       Closure of oral fistula of maxillary
      —Upper or lower jaw, extra-oral                 sinus
      —Biopsy and examination of oral tissue        
                                                       Sequetrectomy for osteomyelitis
      —Study models                                   or bone abscess, superficial
      —Microscopic examination
                                                    
                                                       Condylectomy of temporo-
                                                      mandibular joint
   • Oral surgery, including local anesthet-
     ics and routine postoperative care
                                                    
                                                       Meniscectomy of temporo-
                                                      mandibular joint
      —Extractions
                                                    
                                                       Radial resection of mandible
       
          Uncomplicated
                                                      with bone graft
       
          Surgical removal of erupted tooth         
                                                       Crown exposure to aid eruption
       
          Postoperative visit (sutures and          
                                                       Removal of foreign body from
          complications) after multiple
                                                      soft tissue
          extractions and impaction
                                                    
                                                       Frenectomy
      —Impacted teeth
                                                    
                                                       Suture of soft tissue injury
       
          Removal of tooth
                                                    
                                                       Injection of sclerosing agent into
      —Alveolar or gingival reconstructions
                                                      temporomandibular joint
       
          Alveolectomy (edentulous) per             
                                                      Treatment of trigeminal neuralgia
          quadrant
                                                      by injection into second and third
       
          Alveolectomy (in addition to                divisions
          removal of teeth) per quadrant
                                               • General anesthetics—when provided
       
          Alveoplasty with ridge extension,      in conjunction with an eligible surgical
          per arch                               procedure
       
          Removal of exostosis                 • Periodontics
       
          Excision of hyperplastic tissue,        —Emergency treatment (periodontal
          per arch                                   abscess, acute periodontitis, etc.)
       
          Excision of pericoronal gingiva         —Subgingival curettage or root plan-
       
          Odontogenic cysts and neoplasms            ing and scaling, per quadrant (not
       
          Incision and drainage of abscess           prophylaxis), limited to four quad-
       
          Removal of odontogenic cyst                rants per year
          or tumor                                —Correction of occlusion related to
                                                     periodontal surgery, per quadrant
                                                  —Gingivectomy (including post-
                                                     surgical visits) per quadrant

                                                                                                       17
UPS
HEALTH        —Gingivectomy, treatment per tooth               —Crowns
                (fewer than five teeth)                          
                                                                   Stainless steel (when tooth cannot
PROGRAM       —Osseous or muco-gingival surgery                   be restored with a filling material)
                (including post-surgical visits)                 
                                                                   Crown build-up—will be reviewed
              —Crown lengthening—reviewed on                      by a dental consultant for necessity
Schedule        a per claim basis. Predeterminations           —Full and partial denture repairs
115             are suggested.                                   
                                                                   Broken dentures, no teeth involved
           • Endodontics                                         
                                                                   Partial denture repairs (metal)
              —Pulp capping                                      
                                                                   Replacing missing or broken teeth
              —Therapeutic pulpotomy (in addition                 except congenitally missing teeth
                to restoration)                                —Adding teeth to partial denture to
              —Vital pulpotomy                                   replace extracted natural teeth
              —Remineralization (calcium hydrox-                 
                                                                  Teeth and clasps
                ide, temporary restoration) as a sep-          —Recementation
                arate procedure only                             
                                                                   Inlay
              —Root canals (devitalized teeth only),             
                                                                   Crown
                including necessary X-rays and cul-
                tures, but excluding final restoration
                                                                 
                                                                   Bridge
               
                  Canal therapy (traditional or                —Repairs—crowns and bridges
                  Sargenti method)                          • Space maintainers including all adjust-
               
                  Single rooted                               ments within six months after installation
               
                  Bi-rooted                                    —Fixed space maintainer (band type)
               
                  Tri-rooted                                   —Removable acrylic with round wire
                                                                 rest only
               
                  Apicoectomy (separate procedure)
                                                               —Removable inhibiting appliance
           • Basic restorations excluding inlays,
                                                                 to correct thumb sucking
             crowns (other than stainless steel) and
             bridges. Multiple restorations in one             —Fixed or cemented inhibiting appli-
             surface are considered as a single                  ance to correct thumb sucking
             restoration.
                                                         Major Services
              —Restorations (involving one,              These services are covered at 80 percent
                two or three or more surfaces)           after the Plan deductible has been met:
               
                  Amalgam filling                           • Major restorative—gold restorations,
               
                  Silicate cement filling                     inlays, onlays and crowns are covered
               
                  Plastic filling                             only for treatment of decay or traumatic
               
                  Composite filling—the alternate             injury and only when teeth cannot be
                  benefit of an amalgam filling               restored with a filling material or when
                  will be given when placed on                the tooth is an abutment to a fixed bridge
                  posterior teeth                             or partial denture. Only restorations
              —Pins                                           needed for severe attrition, abrasion
                                                              or erosion are covered.
               
                  Pin (retention) when part of the
                  restoration used instead of gold             —Inlays and onlays
                  or crown restoration                           
                                                                   One or more surfaces

18
UPS
   —Crowns                                          
                                                      Additional clasps                        HEALTH
    
       Acrylic                                      
                                                      Stress breakers
    
       Acrylic with gold                            
                                                      Stayplate, base-additional clasps      PROGRAM
    
       Acrylic with non-precious metal              
                                                      Office reline, cold cure, acrylic
    
       Porcelain                                    
                                                      Laboratory reline                        Schedule
       Porcelain with gold                            Special tissue conditioning,
                                                                                                    115
                                                   

    
       Porcelain with non-precious metal              per denture
    
       Non-precious metal (full cast)               
                                                      Denture duplication (jump case),
    
       Gold (full cast)                               per denture
    
       Gold (3/4 cast)
                                                    
                                                      Adjustment to denture more than
                                                      six months after installation
    
       Gold dowel pin
                                               • Other services
• Prosthondontics
                                                 —Precision attachments (eligible
   —Bridge abutments
                                                    with dentures if they are func-
     (see inlays and crowns)
                                                    tionally necessary)
   —Pontics
                                                 —Implants (if specifically approved
    
       Cast gold (sanitary)                         in advance and the teeth are extracted
    
       Cast non-precious metal                      or missing while covered by the Plan)
    
       Slotted facing
    
       Slotted pontic
                                             Alternate Benefit Provision
    
       Porcelain fused to gold
                                             In some circumstances, an alternate service
    
       Porcelain fused to non-precious       or supply may be suitable to treat or restore
       metal                                 a dental condition, other than the service
   —Removable bridge (unilateral)            or supply recommended by your dentist.
    
       One piece casting, chrome cobalt      In this case, the Plan will pay only for the
       alloy clasp attachment (all types),   alternate service or supply. If you choose
       including pontics                     the recommended course of treatment,
   —Dentures and partials (fees for den-     you’ll be responsible for the difference
     tures, partial dentures and relining    between the recommended course and the
     include adjustments within six          alternate benefit. For example: Your dentist
     months after installation. Special-     may recommend a composite (white) fill-
     ized techniques and characteriza-       ing for a posterior tooth. An appropriate
     tions are not eligible.)                alternate treatment is an amalgam filling.
    
       Complete upper denture                The Plan will only pay for the amalgam
    
       Complete lower denture                filling. If you wish to have the composite
                                             filling, you must pay the difference between
    
       Partial acrylic upper or lower with
                                             the composite and the amalgam filling.
       chrome cobalt alloy clasps, base,
                                             While predetermination is not required,
       all teeth and two clasps
                                             you may wish to submit your course of
    
       Partial lower or upper with           treatment in advance so you know what
       chrome cobalt alloy lingual or        amount the Plan will pay (see “Predeter-
       palatal bar and acrylic saddles,      mination of Benefits”).
       base, all teeth and two clasps

                                                                                                      19
UPS
HEALTH     Orthodontia                                       The Plan covers 50 percent of the R&C
           The Plan allows benefits for orthodontics         cost of TMJ therapy up to a $1,500 lifetime
PROGRAM    for your dependent children under 19 years        maximum. The $1,500 lifetime maximum
           of age. Services provided by December 31          TMJ benefit is combined with the ortho-
           of the year in which your child turns 19          dontia maximum for dependent children.
Schedule   are covered, as long as the treatment began
                                                             What’s Not Covered By Your
115        before the child’s 19th birthday. The Plan
                                                             Dental Benefits
           pays 50 percent of the R&C charges for
           orthodontia, up to a $1,500 lifetime maxi-        In addition to services not specifically listed
           mum for each child. This maximum includes         in the “Covered Expenses” section, the
           treatment for TMJ syndrome (described             following expenses are not covered by
           below) for children under age 19.                 the dental portion of the Plan:
                                                                • Services not required for the treatment
           Orthodontia benefits are not subject to the            of a specific condition or to maintain
           annual deductible. Orthodontic payments                good dental hygiene, as determined by
           are made on a monthly basis. The first pay-            the claims administrator
           ment is equal to 50 percent of the down              • Services not reasonably necessary or
           payment plus 50 percent of the fee for the             customarily performed, as determined
           diagnostic records. However, quarterly                 by the claims administrator
           certification is required to verify that treat-
                                                                • Services not furnished by a licensed
           ment is continuing. Payments begin when
                                                                  dentist, except services provided by
           an active appliance is installed in your
                                                                  a licensed hygienist under the direction
           child’s mouth.
                                                                  of a dentist or X-rays ordered by
           Covered orthodontic services are:                      a dentist
             • Initial consultation                             • Services for which you would not
                                                                  be required to pay in the absence
             • Moldings and impressions
                                                                  of dental coverage
             • Installation of braces
                                                                • Charges covered by the Plan’s
             • Regular visits                                     medical options
           Before treatment begins, the orthodontist            • Treatment of a work-related injury
           should submit a total treatment plan to the          • Services furnished by or for the United
           claims administrator for approval. In this             States government or for any other
           way, you and the orthodontist will know                government, including a service that
           what treatment will be covered.                        may be covered by a government plan
                                                                • Charges for a missed or broken
           Temporomandibular Joint                                appointment
           (TMJ) Therapy                                        • Charges for the dentist’s travel
           Temporomandibular joint dysfunction is               • Occlusal adjustment (unless following
           covered for adults and dependent children.             periodontal surgery) or retainers if
           This coverage is for TMJ appliance therapy             charged separately from orthodontic
           (bite splints), adjustments and diagnostic             treatment
           materials (including impressions) only.
                                                                • Claims received more than 24 months
                                                                  past the date of service

20
UPS
• Intravenous sedation, except in certain    • Replacement or modification of a            HEALTH
  circumstances. Call Member Services          partial or fully removable denture,
  to determine if covered.                     a removable bridge or fixed bridgework,   PROGRAM
• Appliances, restoration or procedures        or for adding teeth to any of these,
  needed to alter vertical dimensions          or for replacement or modification
  or restore occlusion or for the purpose      of an inlay, onlay, crown or cast           Schedule
  of splinting or correcting non-severe        processed restoration, within five               115
  attrition or abrasion                        years after installation
• Dentures and bridgework when they          • Actisite
  are for the replacement of teeth that      • Local anesthesia or nitrous oxide
  were extracted before the patient            as a separate charge
  was covered by the Plan                    • Any prescription drug
• Orthodontic treatment begun before         • Full mouth debridement
  covered by the Plan                        • Guided tissue regeneration
• Root canal therapy if the pulp chamber     • Desensitization treatment
  was opened before the patient was
                                             • Precision attachments except as noted
  covered by the Plan
                                               under “Major Services”
• Relines and adjustments of dentures
                                             • Infection control
  and partial dentures within six months
  after installation                         • Behavior management
• Cosmetic dental services and supplies,     • Canal preparation, if submitted
  including personalization or characteri-     as a separate charge
  zation of dentures                         • Rubber dam
• Prosthetic devices and appliances,
  including bridges and crowns, and
  expenses for fitting or modifying
  them, if the patient is not covered by
  the UPS Health Program when they
  are ordered, when an impression was
  made or when a tooth was prepared.
  The above are also not covered if
  installed or delivered more than 30
  days after the patient’s coverage ends.
• Replacement of lost, stolen or broken
  appliances
• Replacement of congenitally
  missing teeth
• Dental implants (unless specifically
  approved in advance)
• Education programs, such as plaque
  control or oral hygiene instruction

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