If you are dissatisfied with the decision after you have pursued these steps, you have the right to file a lawsuit in a state or federal court. XII. HEALTH CARE CLAIM PROCEDURES For all non-health care claims under the Plan, the following procedures set forth in Sections 11.2 through 11.5 will apply. For all health care claims relating to your Health Care Flexible Spending Account, this Article XII will apply. Despite any other provision of the Plan, the claims procedures of any third-party administrator of the Plan will supersede the procedures set forth below as long as such procedures comply with applicable law. 12.1 Health Care Claim Definition How you file a health care claim for benefits depends on the type of claim it is. There are several categories of benefits: (i) A "concurrent care claim" is a claim for an extension of the duration or number of treatments provided through a previously-approved benefit claim. (ii) A "pre-service care claim" is a claim for a benefit under the Plan with respect to which the terms of the Plan require approval (usually referred to as precertification) of the benefit in advance of obtaining medical care. (iii) A "post-service care claim" is a claim for a benefit under the Plan after medical care has been rendered. (iv) An "urgent care claim" is a claim for medical care or treatment that requires notification or approval prior to receiving medical care, where a delay in treatment could seriously jeopardize your life or health or the ability to regain maximum function or, in the opinion of a doctor with knowledge of your health condition, could cause severe pain. This type of claim generally includes those situations commonly treated as emergencies. 12.2 Filing A Health Care Claim If you wish to designate an authorized representative to act on your behalf with respect to your claim for benefits, you must do so in writing. Please be advised that no rights under the Plan, including but not limited to the right to receive any benefit or any right to pursue a claim or cause of action, are assignable. Any payment by the Plan directly to a provider pursuant to a written election or purported assignments submitted by a participant or a dependent is provided at the discretion of the Plan Administrator as a convenience to the participant or dependent and does not imply an enforceable assignment of any benefits or the right to pursue a claim or cause of action. The Plan Administrator has established a debit card program for the processing and reimbursement of all eligible health care expenses, and the details of such program will be explained to you if and when the program is established. However, in the absence of a debit card program established under this Plan or if a provider will not accept payment from a debit card under this Plan, all claims must be filed using a written form supplied by the Plan Administrator and may be submitted by U.S. Mail, by hand delivery or by facsimile. The Plan Administrator or its delegee provides forms for filing claims and authorized representative designations under the Plan that must be filed in writing. All claims from your Health Care Flexible Spending Account must be submitted during the Plan Year in which the expenses were incurred. Any claims not submitted on or before 90 days immediately following the close of the Plan Year will be rejected. Your claim for benefits should include the following: (i) the amount and nature of the qualifying health care expense (as described elsewhere in this Summary Plan Description under "Health Care Flexible Spending Account Program") for which you want to be reimbursed; (ii) the date that the care giving rise to the qualifying health care expense was provided; (iii) the name of the person receiving the care if such person is not you, and the relationship of such person to you; (iv) the name of the person to whom, or organization to which, the qualifying health care expense was incurred; (v) that the qualifying health care expense has not been reimbursed, or is not reimbursable, under any other health plan coverage; and (vi) a written statement or receipt from an independent third party that the qualifying health care expense has Page 18

Summary Plan Description for Achieva Section 125 and FSA Plan - Page 18 Summary Plan Description for Achieva Section 125 and FSA Plan Page 17 Page 19