Summary Plan Description

Transcription

1 Summary Plan Description 2015 For you & your family McDonald s Corporation All Eligible Employees Medical Vision Supplement Dental Staff, Restaurant Management, Certified Swing and Primary Maintenance Employee Resource Connection Survivor Benefits Long-Term Disability Healthcare Spending Account Dependent Care Spending Account

2 Who to Call Important Phone Numbers and Web Sites Topic General questions, information McDonald s Medical and Dental Plans Medical, dental claims Hospital precertification Physician nomination PPO provider network Blue Care Connection Other services of BCBSIL Prescription Drug Program (PPO members) Pharmacy network Mail service pharmacy Claims administration Mental Health and Substance Abuse Services (PPO members) Provider network Inpatient precertification Claims administration Employee Resource Connection Counseling services Work/Life program Financial/Legal services Contact McDonald s Service Center Service Center fax: mc.service_center@us.mcd.com addin it up for me web site Available through AccessMCD at Blue Cross and Blue Shield of Illinois /7 Nurseline CVS Caremark To start using mail order: (new prescriptions) (existing prescriptions) GuidanceResources (use McDonald s ID number, MCD721, to register as a new user on your first visit) Vision Supplement Plan Claims for out-of-network benefits Network providers Plan information Spending account claims and information Healthcare Spending Account Dependent Care Spending Account Life insurance conversion Enrollment forms EyeMed Vision Care PayFlex Fax claims to: McDonald s Service Center addin it up for me web site or Service Center Go to addin it up for me from Service Center: or Service Center Fax Back: , option 5

3 IMPORTANT NOTICES Si usted tiene preguntas sobre este material, favor de llamar al centro de servicio de McDonald s (877) Two notices that describe certain medical rights under federal law for women: Page 32 - Certain protections of newborns and mothers after childbirth Page 34 - Rights to certain surgical procedures with respect to a mastectomy Important Notice from McDonald s Corporation About Your Prescription Drug Coverage and Medicare on Page The Health Insurance Portability and Accountability Act (HIPAA) Privacy Notice on Page This notice describes how medical information about you may be used and disclosed and certain rights you have with respect to this information. Availability of Summary Health Information As an employee, the health benefits available to you represent a significant component of your compensation package. They also provide important protection for you and your family in the case of illness or injury. Your health plan offers a series of health coverage options. Choosing a health coverage option is an important decision. To help you make an informed choice, your plan makes available a Summary of Benefits and Coverage (SBC), which summarizes important information about any health coverage option in a standard format, to help you compare across options. The SBCs for the Gold, Silver and Bronze PPOs and the HMOs are available on the web at: (online access by selecting: addin it up for me/health & Protection tab). A paper copy is also available, free of charge, by calling the McDonald s Service Center at (877) (a toll-free number). 1

4 TABLE OF CONTENTS McDONALD S CORPORATION BENEFIT PLAN Page About Your Summary Plan Description 11 If You Have Questions 11 SECTION 1 HEALTH PLAN (Medical, Dental, Vision Supplement) MEDICAL PLAN Medical Plan Highlights 14 Prescription Drug Benefits 15 Eligibility and Enrollment for Benefits-Eligible Crew 16 The Plan 16 Eligibility 16 How Are My Average 30 Hours of Service Calculated? 16 Who Are My Eligible Dependents? 16 How Do I Enroll for Coverage? 17 When Do I Enroll for Coverage? 17 More about Annual Enrollment 18 What Happens If I Don t Qualify as a Benefits-Eligible Crew During a Measurement Period? 18 What If I Don t Enroll When I Become Benefits-Eligible? 18 What If I Change Job Class? 18 What If I Have a Break in Service? 18 Eligibility and Enrollment for Full-Time or Part-Time Staff, Restaurant General Manager or Department Manager, Certified Swing Manager or Primary Maintenance Employees 20 The Plan 20 Eligible Employees 20 Who Are My Eligible Dependents? 20 When and How Do I Enroll for Coverage? 21 Annual Enrollment 21 What If I Don t Enroll When I Become Eligible? 21 When Does Coverage Start? 22 What If I Have a Break in Service? 22 Health Maintenance Organization (HMO) 22 Other Important Enrollment Information (Applies to All Eligible Employees) 24 Special Enrollment 24 Who Pays for Coverage? 25 Special Tax Rules If You Cover a Domestic Partner 25 Life Event Changes 25 Qualified Medical Child Support Orders 26 2

5 Medical Plan Options 27 A Choice Between Three Plans 27 How Your Health Reimbursement Account Works 27 How Your Gold, Silver or Bronze Plan Works 27 Using a PPO Hospital (Inpatient/Outpatient) or Provider 27 PPO Price Calculations 28 Medical Benefits 29 Deductibles 29 Coinsurance 29 Out-of-Pocket Maximum 29 Covered Expenses 30 Mental Health and Substance Abuse Program 37 Inpatient Expenses 37 Inpatient Non-Notification Penalty 37 Outpatient Expenses 37 Accessing the GuidanceResources Network 37 Emergency Care 38 How to File a Claim 38 Prescription Drug Benefit (CVS Caremark) 39 Participating Pharmacies 39 How to Use Your Prescription Drug Plan 39 CVS Caremark Mail Service 40 Out-of Pocket Maximum/Deductible/HRA Funds 40 Generic Drug Program 40 Performance Rx Program 41 Specialty Medication Program 41 Specialty Guideline Management (SGM) 41 Smoking Cessation Prescription Drug Benefit 41 Blue Care Connection 42 Primary Nurse Team 42 Case Management 42 Condition Management Program 42 24/7 Nurseline 43 Special Beginnings Prenatal Care 43 Lifestyle Management 43 Online Tools and Information 43 Discounts on Healthcare Products and Services 43 Precertification for Hospital Stays 44 How it Works 44 Organ and Tissue Transplant Provisions 45 Approved Transplant Services 45 Pre-Authorization Requirements for Payment of Plan Benefits 46 Reduced Benefits for Failure to Use a Facility in the Blue Distinction Centers for Transplants 46 Second Opinion Policy 46 Organ/Tissue Acquisition - Donor Expenses 46 Limitations and Exclusions 46 Non-Covered Expenses 48 Non-Covered General Medical Expenses 48 Non-Covered Specific Medical Expenses 48 Non-Covered Prescription Drugs 50 3

6 Continuation of Coverage While on Leave/Disability 52 Short Term/Long Term Disability 52 Unpaid Medical Leave 53 Personal, Military, Jury Duty or Other Leave 53 Family and Medical Leave 53 When Medical, Dental and Vision Supplement Coverage Ends 55 Your Coverage 55 Your Dependent(s) Coverage 55 Handicapped Children 55 Continuation of Coverage Under COBRA 56 Introduction 56 What is COBRA Coverage? 56 When is COBRA Coverage Available? 57 You Must Give Notice of Some Qualifying Events 57 How is COBRA Coverage Provided? 57 When Can COBRA Coverage End Early? 58 Certificate of Creditable Coverage/COBRA 58 Premium Payments under COBRA 59 Healthcare Spending Account COBRA Coverage 59 Employee Resource Connection COBRA Coverage 59 You May Have Other Group Health Coverage Options in Addition to COBRA Coverage Available to You 59 If You Have Questions 60 Keep Your Plan Informed of Address Changes 60 Plan Contact Information 60 Coordination of Benefits 61 If You Have Other Medical/Dental Care Coverage 61 How Coordination of Benefits Works 61 Rules for Determining the Primary Plan 61 Automobile Insurance 62 Medicare 63 When the Medical Plan Pays First 63 When Medicare Pays First 63 Medicare and Coordination of Benefits 63 Medicare Enrollment Requirements 64 Important Notice From McDonald s About Your Prescription Drug Coverage and Medicare 65 When Can You Join a Medicare Drug Plan? 65 What Happens to Your Current Coverage if You Decide to Join a Medicare Drug Plan 65 When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan 65 For More Information about This Notice or Your Current Prescription Drug Coverage 66 For More Information about Your Options Under Medicare Prescription Drug Coverage 66 Repayments to the Plan 67 Reimbursement to the Plan 67 Subrogation 67 Recovery of Excess Payments 68 Applying for Benefits 69 Pre-Determination of Dental Benefits 69 Eligibility or Enrollment Review 69 Medical/Dental Claims 69 Prescription Drug Claims 70 Mental Health and Substance Abuse Claims 70 Vision Supplement and Healthcare Spending Account Claims 70 Employee Resource Connection 70 4

7 How and When Medical/Dental Plan Claims are Paid 70 Initial Claim Determinations 70 Special Rules for Urgent Care Claims 71 Extension of Time 71 Appeals for Medical, Dental, Employee Resource Connection, and Healthcare 72 Spending Account Claims How to Appeal a Claim Internal Appeal 72 The Internal Appeal Determination by the Claims Administrator 73 Independent External Review 73 Expedited External Review 75 Exhaustion of Review Process 76 McDONALD S VISION SUPPLEMENT PLAN How the Vision Supplement Plan Works 77 Basic Benefits 78 Mail Order Contact Lens Replacement Program 78 Laser Vision Correction 79 Exclusions 79 Coordination of Benefits 79 If a Claim is Denied 79 McDONALD S DENTAL PLAN HIGHLIGHTS McDonald s Dental Plan Highlights 80 Dental Covered Expenses 81 BCBSIL Dental PPO 81 Dental Health Maintenance Organization (DHMO) 81 Dental Plan Provisions 82 Deductibles 82 Annual Maximum 82 Covered Charges 82 How Covered Charges Are Calculated 82 Alternate Procedures 82 Covered Charges for Preventive Services 83 Covered Charges for Emergency Services 83 Covered Charges for Basic and Major Services 83 Orthodontia Benefits 85 Lifetime Deductible, Coinsurance Level and Maximum Benefits 85 Covered Charges 85 Payment Sequence 85 Non-Covered Dental Expenses 85 When Dental Coverage Ends 86 Coordination of Dental Benefits 86 Applying for Benefits 86 5

8 PRIVACY RULES YOUR INFORMATION. YOUR RIGHTS. OUR RESPONSIBILITIES. Your Rights 87 Your Choices 88 Our Uses and Disclosures 88 Our Responsibilities 89 Changes to the Terms of This Notice 89 Other Information 89 SECTION 2 OTHER WELFARE PLANS (Employee Resource Connection, Group Insurance Plan, Spending Account Plans) EMPLOYEE RESOURCE CONNECTION Eligible Employees 94 Enrollment 94 When Does Coverage Begin? 94 How the Employee Resource Connection Works 94 How to Reach the GuidanceResources Program 94 Counseling Services 94 Work/Life Programs 95 Financial Services 95 Legal Services 95 Visiting GuidanceResources Online 96 When Does Coverage End? 96 YOUR GROUP INSURANCE PLAN Overview 97 McDonald s Survivor Benefits Highlights 98 Basic Survivor Insurance Benefits 98 Optional Survivor Insurance Benefits 98 Eligible Employees 99 Enrollment 99 When Does Coverage Start? 99 Cost of Plan 99 Employee Life Insurance Benefits 100 Employee Basic Life Insurance Benefits 100 Funeral Planning Services 100 Employee Optional Term Life Insurance Benefits 100 Cost of the Optional Term Life Plan 100 Amount of Your Optional Term Life Benefits 100 Dependent Life Insurance Benefits 102 Basic Dependent Life Insurance Benefits 102 Eligible Dependents 102 When Does Coverage Start? 102 Cost of the Plan 102 Amount of Your Basic Dependent Life Benefits 102 6

9 Optional Dependent Life Insurance Benefits 102 Electing Optional Dependent Life Coverage and Effective Date of Coverage 102 Late Elections 103 Amount of Your Optional Dependent Life Benefits 103 Who Pays for Coverage? 103 Employee Accidental Death & Dismemberment (AD&D) Insurance 104 Employee Basic AD&D Insurance 104 Employee Basic AD&D Insurance Amount 104 Change in Base Annual Pay 104 Dismemberment Schedule 104 Paralysis Schedule 104 Employee Optional AD&D Insurance 105 Common Carrier Benefit 105 Exclusions 105 Additional AD&D Insurance Benefits 106 Rehabilitative Therapy Benefits 106 Coma Benefit 106 Seat Belt/Airbag Benefit 106 Exposure and Disappearance Coverage 107 Home Alteration and Vehicle Modification Benefit 107 Medical Coverage Funding Benefit 107 Monthly Hospital Benefit 107 Education Benefit for Spouse and/or Child 107 Child Care Benefit 107 Repatriation of Remains Benefits 107 Business Travel Accident Insurance 108 Business Travel Coverage 108 Schedule of Benefits 108 Conditions of Coverage 108 Schedule of Covered Losses 109 Additional Coverage Offered Under Business Travel Accident Insurance 109 Commuting Benefit 109 Bomb Scare, Bomb Search or Bomb Explosion Benefit 109 Dependent Coverage 110 Carjacking Benefit 110 Rehabilitative Therapy Benefits 110 Coma Benefit 110 Seat Belt/Airbag Benefit 111 Exposure and Disappearance Coverage 111 Felonious Assault and Violent Crime Coverage 111 Bereavement and Trauma Counseling Benefit 112 Home Alteration and Vehicle Modification Benefit 112 Exclusions 112 Applying for Survivor Benefits 114 Naming Your Beneficiary 114 When to File a Claim 114 If a Claim is Denied 114 7

10 Payment of Benefits 115 Gift Assignments 115 Accelerated Benefit Option for Terminal Illness 115 Legal Actions 116 When Your Survivor Insurance Ends 117 Situations That May Affect Your Survivor Insurance Benefits 118 If You Are on Leave of Absence 118 If You Are on Long Term Disability 118 When You Reach Age Converting Basic, Optional Term and Dependent Life Coverages 119 LONG TERM DISABILITY Eligibility 120 Eligible Employees 120 Enrollment Process 120 When LTD Coverage Begins 120 Qualifying for LTD Benefits 120 Schedule of Benefits 121 Monthly Basic LTD Benefit 121 Maximum and Minimum Benefit 121 Maximum Benefit Period 121 Increases in LTD Coverage 121 Decreases in LTD Coverage 121 When Your LTD Coverage Ends 122 If You are on a Leave of Absence 122 Reinstatement of Disability Income Insurance 122 Payment of Benefits 122 Recovery From a Disability 122 Rehabilitation and Other Incentives 123 Limitations on Your LTD Benefit 124 Income Which Will Reduce Your LTD Benefit 124 How Your Social Security Benefits Affect Your LTD Benefit 124 Single Sum Payment 124 Income Which Will Not Reduce Your Disability Benefit 125 When LTD Benefit Payments End 125 In the Event of Your Death 125 In the Event of Your Terminal Illness 125 Pre-Existing Conditions 126 Limited LTD Benefits for Certain Conditions 126 Exclusions 126 Applying for Benefits 126 Filing a Claim 126 Initial Determination 127 Appealing the Initial Determination 127 General Provisions 128 Assignment 128 8

11 Who Will Be Paid 128 Physical Exams & Autopsy 128 Overpayments 128 Special Services 128 Social Security Assistance Program 128 Early Intervention Program 129 Return to Work Program 129 HEALTHCARE SPENDING ACCOUNT Eligible Employees 130 Enrollment 130 When Does Coverage Start? 130 Life Event Changes 130 Reducing Your Taxes 131 Contributions 131 Forfeitures 131 Eligible Expenses 132 Filing a Claim 132 PayFlex Service Center 132 Some Healthcare Spending Account Guidelines 133 Special Rules if You Change Your Employment Status 133 Qualified Reservist Distribution 133 When Your Participation in the Healthcare Spending Account Ends 134 COBRA 134 DEPENDENT CARE SPENDING ACCOUNT Eligible Employees 135 Dependents 135 Enrollment 135 When Does Coverage Start? 136 Life Event Changes 136 How the Dependent Care Spending Account Works 136 Contributions 136 Forfeitures 137 Eligible Expenses 137 How Will This Affect the Current Dependent Care Federal Tax Credit? 137 Additional Considerations 137 Filing a Claim 138 If a Claim is Denied 138 Some Dependent Care Spending Account Guidelines 139 PayFlex Service Center 139 Special Rules if You Change Your Employment Status 139 When Your Participation in the Dependent Care Spending Account Ends 139 SECTION 3 GENERAL INFORMATION AND GLOSSARY ADMINISTRATIVE INFORMATION Plan Sponsor 142 Plan Administrator 142 Employer Number 142 Terminations and Amendments 142 Claims Administrators 143 Employee and Dependent Data 144 9

12 Agent for Service of Legal Process 144 Governing Law 144 Plan Year Information 144 Plan Filing and Funding Information 144 Trustee of McDonald s Corporation Welfare Benefit Trust (VEBA) 145 Your ERISA Rights 145 ADMINISTRATIVE SUMMARY 147 GLOSSARY

13 McDONALD S CORPORATION BENEFIT PLANS Your Employee benefits are an important part of your total compensation at McDonald s Corporation ( McDonald s ). This Summary Plan Description ( SPD ) describes the McDonald s Corporation Benefit Plans. The Plans consist of the McDonald s Corporation Health Plan (including the Medical Plan, Vision Supplement Plan and Dental Plan), Employee Resource Connection, Group Insurance Plan (including Life, AD&D, Business Travel Accident and Long Term Disability Insurance), Healthcare Spending Account Plan and Dependent Care Spending Account Plan. The provisions of this SPD are effective January 1, The Benefit Plans are sponsored by McDonald s Corporation and are funded primarily through Employer contributions supplemented by Employee contributions. Benefits under the Medical, Vision Supplement and Dental Plans are self-insured and are funded through the McDonald s Corporation Welfare Benefit Trust. In this SPD, a number of terms are capitalized. For the definition of these terms, see the Glossary at the end of the SPD. About Your Summary Plan Description In some cases, different benefits apply to different groups of Employees. The SPD is divided into three sections and has tabs to help indicate the sections that apply to a particular Employee group. Before you start using this SPD, please be sure to open the tabs so that you can more easily find the benefits available to your Employee group. The chart below shows the Plans and information that apply to each Eligible Employee Group: Who is eligible for the benefits in the Section Section 1 Section 2 Section 3 Full & Part-Time Staff Full & Part-Time Staff Full & Part-Time Staff Restaurant: Restaurant: Restaurant: o General Manager o General Manager o General Manager o Department Manager o Department Manager o Department Manager o Certified Swing o Certified Swing o Certified Swing o Primary Maintenance o Primary Maintenance o Primary Maintenance o Benefits-Eligible Crew o Benefits-Eligible Crew Plan Information in the Section Health Plan (Medical, Vision Supplement and Dental) Benefits provided through: Employee Resource Connection, Group Insurance and Spending Account Plans Benefits provided through: Reference Information Medical Plan: Blue Cross and Blue Shield of Illinois ( BCBSIL ) In certain areas, HMOs Mental Health and Substance Abuse Program: ComPsych through GuidanceResources Prescription Drug Program: CVS Caremark Vision Supplement Plan: EyeMed Vision Care Dental Plan: BCBSIL Employee Resource Connection: ComPsych through GuidanceResources Life Insurance and Accidental Death & Dismemberment/Travel Accident Insurance: Aetna Business Travel Accident Insurance: Cigna Long Term Disability Insurance: MetLife Healthcare Spending Account: PayFlex Dependent Care Spending Account: PayFlex General Information Glossary Remember, your benefit plans are based on legal plan documents, which are available to you upon request. In the case of the Health Plan (Medical, Vision Supplement and Dental Plans) and the Employee Resource Connection, this SPD also serves as the Plan document. If there is any difference between this SPD and the Plan documents, the Plan documents will always govern. If You Have Questions If you have any questions concerning the benefits described in this SPD, contact the McDonald s Service Center for information at (877)

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15 MEDICAL, VISION & DENTAL

16 WHO IS ELIGIBLE FOR BENEFITS IN THIS SECTION: Full & Part-Time Staff Restaurant Employees in the following positions: General Manager Department Manager Certified Swing Primary Maintenance Benefits-Eligible Crew 13

17 GOLD PLAN SILVER PLAN BRONZE PLAN Hospitalization Non-Notification Penalty A $250 penalty applies if BCBSIL or ComPsych (for MH/SA) is not contacted prior to a Hospital confinement on a timely basis. In the case of an Emergency Hospital Admission, BCBSIL or ComPsych must be notified within two working days after the date of confinement begins. Applies to each individual for each Hospital Confinement. MEDICAL PLAN HIGHLIGHTS PPO Medical and Mental Health/Substance Abuse (MH/SA) Benefits Employer-Provided Health Reimbursement Account HRA All Eligible Employees except Benefits- Eligible Crew $250 (Employee Only) $500 (2 or more Covered People) $375 (Employee Only) $750 ( 2 or more Covered People) $375 (Employee Only) $750 (2 or more Covered People) HRA Funding Benefits-Eligible Crew Only Annual Deductible (HRA contribution counts towards your Deductible) Coinsurance Level: Percentage paid by Plans for Covered Expenses, after Deductible, prior to Out-of- Pocket Maximum, subject to Reasonable and Customary Charges for Out-of-Network $500 (Employee Only) $1,000 (2 or more Covered People) $1,000 (Employee Only) $2,000 (2 or more Covered People) In-Network Medical Services: 80% Inpatient MH/SA: 80% Outpatient MH/SA: -100% after $10 Copay with no Deductible if precertified -80% if not precertified $750 (Employee Only) $1,500 (2 or more Covered People) $2,000 (Employee Only) $4,000 (2 or more Covered People) In-Network Medical Services: 75% Inpatient MH/SA: 75% Outpatient MH/SA: -100% after $10 Copay with no Deductible if precertified -75% if not precertified $750 (Employee Only) $1,500 (2 or more Covered People) $3,175 (Employee Only) $6,350 (2 or more Covered People) In-Network Medical Services: 65% Inpatient MH/SA: 65% Outpatient MH/SA: -100% after $10 Copay with no Deductible if precertified -65% if not precertified Out-of-Network Medical and MH/SA Services: 50% Emergency Room Visit Copay: 1 visit per Covered Person $100 Copay After 1 visit per Covered Person $200 Copay If you are admitted to the Hospital, the Copay is waived. The Copay is in addition to your Deductible and Coinsurance. Out-of-Pocket Maximum for In-Network Medical and MH/SA, & all Prescription Drugs $4,000 (Employee Only) $8,000 (2 or more Covered People) $6,350 (Employee Only) $12,700 (2 or more Covered People) $6,350 (Employee Only) $12,700 (2 or more Covered People) Out-of-Pocket Maximum for Out-of- Network Medical & MH/SA only $8,000 (Employee Only) $16,000 (2 or more Covered People) $12,700 (Employee Only) $25,400 (2 or more Covered People) $12,700 (Employee Only) $25,400 (2 or more Covered People) 14

18 GOLD PLAN SILVER PLAN BRONZE PLAN Prescription Drug Benefits: Your Costs No Deductible/No HRA Funds Available for Prescription Drugs *30-day supply or less: In-Network Pharmacy CVS Caremark network Generic: 10% Coinsurance /$10 max Preferred Brand: 20% Coinsurance /$30 max Generic: 20% Coinsurance /$20 max Preferred Brand: 30% Coinsurance /$40 max Generic: 20% Coinsurance /$20 max Preferred Brand: 30% Coinsurance/ $40 max Non-Preferred Brand: 40% Coinsurance/ $60 max Non-Preferred Brand: 50% Coinsurance/ $70 max Non-Preferred Brand: 50% Coinsurance / $70 max *30-day supply or less: Out-of-Network Retail Pharmacy NOT in CVS Caremark network 50% Coinsurance + $5 Copay for Generic & Brand Name (Max claim amount allowed: $2,000) 90-day supply: applies only to CVS Mail Service Program or CVS Retail Pharmacy Generic: 10% Coinsurance /$25 max Preferred Brand: 20% Coinsurance /$75 max Non-Preferred Brand: 40% Coinsurance / $150 max Generic: 20% Coinsurance /$50 max Preferred Brand: 30% Coinsurance /$100 max Non-Preferred Brand: 50% Coinsurance / $175 max Generic: 20% Coinsurance /$50 max Preferred Brand: 30% Coinsurance /$100 max Non-Preferred Brand: 50% Coinsurance / $175 max CVS Specialty Prescription Program 30 day supply or less $300 Copay *Plus $25 penalty on maintenance drugs after three (3) 30-day refills 15

19 ELIGIBILITY AND ENROLLMENT FOR BENEFITS-ELIGIBLE CREW The Plan For purposes of the following enrollment and cost provisions, Plan refers to the Medical, Vision Supplement and Dental Plans. Eligibility You and your Dependents are eligible for the Plan if you are a Benefits-Eligible Crew Employee. For purposes of the Plan, Benefits-Eligible Crew means any Crew Employee who works on average at least 30 Hours of Service a week over a 12- month period. Crew means any restaurant Employee other than a General Manager, Department Manager, Certified Swing Manager or Primary Maintenance Employee. (Hawaii and Guam Crew Employees have their own eligibility rules that are described in a separate SPD for them.) How Are My Average 30 Hours of Service Calculated? New Hires: As a newly hired Crew, you must work on average at least 30 Hours of Service a week during your Anniversary Year in order to qualify as a Benefits-Eligible Crew. This means that you must work at least 1,560 Hours of Service in your Anniversary Year. Your Anniversary Year is your first year of employment, starting on your hire date. Ongoing Employees: If you don t qualify as a Benefits-Eligible Crew at the end of your Anniversary Year, you can also become a Benefits-Eligible Crew if you work at least 1,560 Hours of Service in any Measurement Year. A Measurement Year starts on October 3 rd of each year and ends on October 2 nd of the next year. The Plan uses a methodology to calculate your service solely for purposes of determining whether you are a Benefits-Eligible Crew. For more information, or to obtain a description of the Plan s requirements concerning eligibility for participation, please contact the McDonald s Service Center. Who Are My Eligible Dependents? Your eligible Dependents are: Your Spouse or Domestic Partner. For definition of Spouse and Domestic Partner eligibility requirements, see the Glossary. Your children under age 26 (and older if handicapped and dependent on you for care and support). "Children" include any of the following children of you, your Spouse or your Domestic Partner: Natural child(ren). Step-child(ren). Foster child(ren). Legally adopted child(ren) (including child(ren) who have been placed with you for adoption). Child(ren) for whom you, your Spouse or your Domestic Partner are a legal guardian. Unless one of the above relationships applies, the following are not considered your eligible Dependents for Plan coverage: grandchildren, nieces, nephews, cousins, parents or any similar blood relations, even when they are living with you and depend on you for care and support. No person can be covered both as an Employee and as a Dependent under the Plan. No person can be covered as a Dependent of more than one Employee under the Plan. 16

20 For purposes of the Plan, your Domestic Partner will be treated the same as a Spouse unless otherwise noted. The Plan Administrator may check from time to time to make sure your covered family members qualify as Dependents. You must provide proof that your covered family members qualify as Dependents. See When Coverage Ends for more information on what happens if the Plan Administrator finds out that your covered family members do not qualify as your Dependents. Also, when you enroll a Dependent, you must submit certain documents to show the Service Center that your Dependents are eligible. If you don t provide those documents to the Service Center, your Dependents could lose their coverage going forward but your premiums will stay the same. If the Plan Administrator finds that you fraudulently added a Dependent, the Plan Administrator may take away that Dependent s coverage retroactively and require you to pay the Plan back for claims that were paid for that Dependent. How Do I Enroll for Coverage? Once you qualify as a Benefits-Eligible Crew, you must enroll in order to get Plan coverage. Also, you must enroll yourself for coverage in order to enroll your Dependents. You may make separate enrollments under the Medical Plan, Vision Supplement Plan and Dental Plan. This means that you can elect Medical Plan coverage only, or Vision Supplement Plan coverage only, or Dental Plan coverage only, or any combination of the three Plans. Your Medical coverage choices are the Gold, Silver and Bronze Plans. See Medical Benefits below for a description of those Medical Plans. You will be able to elect one of these coverage levels: Employee Only Coverage just for yourself Employee & Spouse or Domestic Partner Coverage for just you and your Spouse or Domestic Partner Employee & Children Coverage for just you and your children (not your Spouse or Domestic Partner) Family with Spouse or Domestic Partner Coverage for you, your children and your Spouse or Domestic Partner Also, you can elect coverage for just yourself ( Employee Only coverage) under one Plan and coverage for you and your Dependents (either Employee & Spouse or Domestic Partner, Employee & Children, or Family with Spouse or Domestic Partner) under another Plan. Example: Jane wants to have coverage just for herself for Medical, because the rest of her family is covered under her spouse s employer medical plan. But she wants to cover her husband and children under the Dental and Vision Plans. She can elect Employee Only Medical coverage for herself and Family with Spouse Dental and Vision coverage for the rest of her family. When Do I Enroll for Coverage? New Hires: If you become a Benefits-Eligible Crew as a new hire, McDonald s will send you instructions when your Anniversary Year ends. The Service Center must receive your completed enrollment elections for you and your Dependents by the end of the first full calendar month after your Anniversary Year ends. There is also a 60-day grace period to enroll after that calendar month ends. Contact the Service Center for more information on the grace period. Then your coverage will start as of the first day of the month after you enroll. You must enroll in order to get coverage. Example: Joe was hired as a Crew Employee on January 15, 2015 and completed 1,560 Hours of Service in his first year of hire by January 14, He must enroll himself (and his Dependents) by February 28, If he does enroll by that date, his coverage will be effective March 1, Ongoing Crew Employees: If you become a Benefits-Eligible Crew at the end of a Measurement Year (so you complete 1,560 Hours of Service in the Measurement Year), you will be able to enroll yourself and your Dependents during the annual enrollment that starts after the end of that Measurement Period. If you enroll during annual enrollment, your coverage will be effective on January 1 st of the next year. Example: If Joe didn t complete 1,560 hours in his Anniversary year that ended on May 31, 2016, but did complete 1,560 hours during the Measurement Year ending October 2, 2016, he will be eligible to enroll in the Plan. He must do so during the annual enrollment for His coverage would be effective January 1, Each year that you complete 1,560 Hours of Service during a Measurement Period, you will be eligible to enroll in the Plan during the next annual enrollment. 17

21 More about Annual Enrollment If you qualify as a Benefits-Eligible Crew during a Measurement Period, then during the next annual enrollment you can start, change or stop your healthcare coverage for the next Calendar Year. Annual Enrollment starts a few weeks after the Measurement Period ends. Before annual enrollment starts, you will be told whether you are eligible to be a Benefits-Eligible Crew for the next Calendar Year s coverage, the healthcare benefits available and the dates for the annual enrollment. Benefit choices made during annual enrollment will become effective on the following January 1 st. Once you make your Medical, Dental and/or Vision coverage election during annual enrollment, it will stay in effect from Calendar Year to Calendar Year for as long as you continue to be a Benefits-Eligible Crew, unless you change it during a later annual enrollment. You can also make changes to your enrollment if you have a qualifying life event or Special Enrollment Period described in Other Important Enrollment Information for All Eligible Employees below. What Happens If I Don t Qualify as a Benefits-Eligible Crew During a Measurement Period? If you are already in the Plan, but you don t complete 1,560 Hours of Service during a Measurement Period, your coverage will end at the end of the current Calendar Year and you will not be able to enroll in the Plan during annual enrollment for the next Calendar Year. Example: Suppose Joe does enroll in the Plan during annual enrollment in He has coverage for all of However, he does not work 1,560 Hours of Service in the Measurement Period ending October 2, This means that he cannot enroll in the Plan for 2018 and his coverage will end on December 31, What If I Don t Enroll When I Become Benefits-Eligible? If you are eligible to enroll as a Benefits-Eligible Crew (either during your Anniversary Year or at the end of any Measurement Period) but you choose not to enroll yourself and/or your Dependents at that time, you ll have to wait until the next annual enrollment to enroll, unless you qualify for a Special Enrollment Period or have a life event change. If you have Employee Only coverage and you fail to enroll a newly acquired Dependent within the Special Enrollment Period, you must wait until the next annual enrollment to enroll the new Dependent. What If I Change Job Class? If you transfer from a Crew position to a Restaurant Manager, Department Manager, Certified Swing, Primary Maintenance or Full-Time or Part-Time Staff Employee, the following applies: If you are already in the Plan, your coverage under the Plan will just continue. If you were eligible to enroll as a Benefits-Eligible Crew but did not enroll, you will not be able to enroll in the Plan after your transfer until the next annual enrollment (unless you qualify for Special Enrollment or have a life event change.) If you were not yet eligible to enroll in the Plan, you will be able to elect coverage under the Plan after your transfer. In any event, after your transfer you will become eligible for life, accident, and disability insurance as well as the Healthcare and Dependent Care Spending Accounts described later in this SPD. To elect coverage available to you after your transfer, you must enroll by the end of your first full calendar month in your new job. Coverage will be effective the first day of the next month. In certain locations, a Health Maintenance Organization (HMO) may be available to you as a Medical Plan alternative after you transfer. If you work at a location that has an HMO option, contact the McDonald s Service Center for details. For more information on your benefits if you have a transfer described above or if you transfer to a Crew position from a Full or Part-Time Staff, Restaurant Manager, Department Manager, Certified Swing or Primary Maintenance Employee position, contact the McDonald s Service Center to find out when you will be eligible for coverage under the Plan. What If I Have a Break in Service? If you stop working for any reason and return to work in less than 13 weeks: 18

22 Any Hours of Service that you worked before you left will count towards determining your Benefits-Eligible Crew status when you return. You will not get credit for the time you were gone. However, if you left due to military, jury duty or FMLA leave, you will be credited with 30 Hours of Service for each week that you were on leave, just for purposes of determining your Benefits-Eligible Crew status. If you were already an eligible Benefits-Eligible Crew when you left and you return in the same Calendar Year, you will be considered a Benefits-Eligible Crew when you return for the rest of the year. Also, your prior election will be reinstated when you return, or if you were gone for more than 30 days, you can make a new election. If you stop working for any reason for 13 weeks or more and then you come back to work, you have a Break in Service. In that case, any Hours of Service that you had before you stopped working will not count towards determining your Benefits-Eligible Crew status and you will be treated as a new hire when you come back to work. If you stopped working due to a leave of absence, also see Continuing Your Coverage While on Leave of Absence below to see how your absence affects your Plan coverage. 19

23 ELIGIBILITY AND ENROLLMENT FOR FULL-TIME or PART-TIME STAFF, RESTAURANT GENERAL MANAGER or DEPARTMENT MANAGER, CERTIFIED SWING MANAGER or PRIMARY MAINTENANCE EMPLOYEES The Plan For purposes of the following enrollment and cost provisions, the term Plan refers to the Medical, Vision Supplement and Dental Plans. Eligible Employees You are an Eligible Employee if you are a Full-Time or Part-Time Staff, Restaurant General Manager, Department Manager, Certified Swing Manager or Primary Maintenance Employee on the U.S. payroll of McDonald s or another Employer. Full- Time means you are regularly scheduled to work at least 35 hours per week. Part-Time means you are regularly scheduled and working at least 20 hours per week. Who Are My Eligible Dependents? Your eligible Dependents are: Your Spouse or Domestic Partner. For definition of Spouse and Domestic Partner eligibility requirements, see the Glossary. Your children under age 26 (and older if handicapped and dependent on you for care and support). "Children" include any of the following children of you, your Spouse or your Domestic Partner: Natural child(ren). Step-child(ren). Foster child(ren). Legally adopted child(ren) (including child(ren) who have been placed with you for adoption). Child(ren) for whom you, your Spouse or your Domestic Partner are a legal guardian. Unless one of the above relationships applies, the following are not considered your eligible Dependents for Plan coverage: grandchildren, nieces, nephews, cousins, parents or any similar blood relations, even when they are living with you and depend on you for care and support. No person can be covered both as an Employee and as a Dependent under the Plan. No person can be covered as a Dependent of more than one Employee under the Plan. For purposes of the Plan, your Domestic Partner will be treated the same as a Spouse unless otherwise noted. Eligibility rules for Dependents may vary if you are covered by an HMO. Check with your HMO for specific information about Dependent coverage. The Plan Administrator may check from time to time to make sure your covered family members qualify as Dependents. You must provide proof of Dependent status. See When Coverage Ends for more information on what happens if the Plan Administrator finds out that your covered family members do not qualify as your Dependents. Also, when you enroll a Dependent, you must submit certain documents to show the Service Center that your Dependents are eligible. If you do not provide those documents to the Service Center, your Dependents could lose their coverage going forward but your premiums will stay the same. If the Plan Administrator finds that you fraudulently added a Dependent, the Plan Administrator may take away that Dependent s coverage retroactively and require you to pay the Plan back for claims that were paid for that Dependent. 20

24 When and How Do I Enroll for Coverage? You must enroll in order to get Plan coverage. Also, you must enroll for Employee coverage in order to enroll for Dependent coverage. You may make separate enrollments under the Medical, Vision Supplement and Dental Plans. This means that you can elect Medical Plan coverage only, or Vision Supplement Plan coverage only, or Dental Plan coverage only, or any combination of the three Plans. Your Medical Plan choices are the Gold, Silver and Bronze Plans and, if you work in certain areas a Health Maintenance Organization or HMO. (If you work in Guam, your only choice is the Guam HMO for Medical and Dental benefits.) See Medical Benefits below for a description of the Gold, Silver and Bronze Plans. You will be able to elect one of these coverage levels: Employee Only Coverage just for yourself Employee & Spouse or Domestic Partner Coverage for just you and your Spouse or Domestic Partner Employee & Children Coverage for just you and your children (not your Spouse or Domestic Partner) Family with Spouse or Domestic Partner Coverage for you, your children and your Spouse or Domestic Partner Also, you can elect coverage for just yourself (Employee Only coverage) under one Plan and coverage for your Dependents (either Employee & Spouse or Domestic Partner, Employee & Children, or Family with Spouse or Domestic Partner) under another Plan. For example, you can elect Medical Plan Employee Only coverage for yourself, and then elect Dental Plan and/or Vision Supplement Plan Employee & Spouse coverage for you and your Spouse. When you become eligible for benefits, you will receive instructions on how to enroll for coverage. McDonald s must receive your completed elections for Employee (and, if applicable, Dependent) coverage before the end of your waiting period. Your waiting period is one calendar month of service in the eligible position (4 consecutive weeks of service if you reside in Hawaii or Guam). You must enroll during your waiting period. If you do not enroll during this time period, you will have to wait until the next annual enrollment to enroll, unless you have a life event change (see below). If you are a new hire or are newly eligible and are enrolling in the Gold, Silver or Bronze Plans, Dental Plan and/or Vision Supplement Plan, there is a 60-day grace period after your waiting period ends to enroll. This grace period may not apply for certain HMOs. Contact the Service Center for more information on the grace period. If you do not have a Dependent when you enroll, you must enroll for Dependent benefits within the Special Enrollment Period described below. If you were employed in a class of Employees that are not Eligible Employees and you become an Eligible Employee, you must complete the above waiting period after becoming an Eligible Employee and submit an enrollment form before the end of that waiting period in order to enroll for coverage. If you transfer to McDonald s from a benefits-eligible position at another Employer, your service in the benefits-eligible position with the Employer will count towards your waiting period under the Plan. If you elect coverage under a health maintenance organization (HMO) or a dental health maintenance organization (DHMO), you must also complete an HMO or DHMO application form. Annual Enrollment Annual enrollment is a period of time each year during which you can start, change or stop your current healthcare coverage. Before annual enrollment, you will receive information about the healthcare benefits available and the dates of the annual enrollment period. What If I Don t Enroll When I Become Eligible? If McDonald s does not receive your enrollment form by the end of your initial waiting period, you and your Dependents will be considered late enrollees and cannot enter the Plan until the next annual enrollment period unless you qualify for Special Enrollment or have a life event change described below. 21

25 If you have Employee Only coverage and you fail to enroll a newly acquired Dependent within the Special Enrollment Period, you must wait until the next annual enrollment unless you have a life event change. When Does Coverage Start? Your Employee and Dependent coverage starts on the first day of the month following the end of your waiting period, assuming you have enrolled for that coverage prior to that date. If you enroll yourself or your Dependent(s) through annual enrollment, coverage will start on the next January 1 st. If you enroll yourself or your Dependent(s) due to Special Enrollment or a life event change, see Other Important Enrollment Information to find out when coverage becomes effective. Once your election becomes effective, it will remain in effect for the rest of that Calendar Year. Your election will also stay in effect from Calendar Year to Calendar Year. However, you can change your election during a later annual enrollment or if you qualify for an enrollment change due to a Special Enrollment Period or other life event change. (See Important Enrollment Information for All Eligible Employees below.) Important Note: During the annual enrollment in November, 2014 for Medical Plan coverage in 2015, if you are enrolled in the Core or Classic Plan and do not elect one of the new Gold, Silver or Bronze Plans available for 2015, you will automatically be enrolled in the Silver Plan for What If I Have a Break in Service? If you stop working for any reason for less than 13 weeks and return to work in an eligible position, you will be eligible for coverage when you return and do not have to complete the one month waiting period when you return to work. If you were covered under the Plan when you left, you will be able to reinstate your prior election when you return or, if you were gone for more than 30 days or you return in a new Calendar Year, you can make a new election for coverage. If you stop working for any reason other than a leave of absence for 13 weeks or more and then you come back to work, you will be treated as a new hire when you come back. If you stopped working due to a leave of absence, also see Continuing Your Coverage While on Leave of Absence below to see how your absence affects your Plan coverage. Health Maintenance Organization (HMO) In certain locations, a Health Maintenance Organization (HMO) may be available as a Medical Plan alternative. If you work at a location that has HMO options, contact the McDonald's Service Center for details. Many of the requirements, such as eligibility, enrollment and changes to enrollment, covered benefits and benefit exclusions differ from the McDonald s Medical Plans and will differ among the various HMOs available, depending on the state in which the HMO is located. For example, HMO options are not available to certain Domestic Partners or the HMO may have different eligibility rules for Domestic Partners. If you are interested in enrolling in an HMO, it is important that you check with the HMO on the benefits covered, any requirements for coverage and how the HMO is administered. Once you receive the information, you will have the opportunity to choose between the HMO and the McDonald s Medical Plans. HMO participants are required to obtain care from the Providers of medical services who are affiliated with the HMO. Employees in Guam will only have the choice of the Netcare HMO available in Guam, because the PPO network for the McDonald s Medical Plans is not available in Guam. If you choose an HMO, the Medical Plan provisions that follow (other than the Other Important Enrollment Information, Continuation of Coverage Under COBRA and Privacy Rules section) will not apply to you. Instead, you will receive a separate summary of HMO medical benefits. You should keep this SPD and your HMO summary together for a complete description of your benefits and rights under the Plan. If you elect medical coverage through an HMO and dental coverage under the McDonald s Dental Plan, you should note that oral surgical procedures and dental treatment due to accidental injury may not be covered under the HMO because the HMO may treat such procedures as dental care. However, the McDonald s Dental Plan does not cover oral surgical procedures. Therefore, you may not have coverage for oral surgical procedures under either the HMO or the McDonald s Dental Plan. 22

26 The HMOs establish rates every year. McDonald s and you share contributions for the healthcare service you receive through the HMO. These rates can change from time to time. For the rates applicable to HMOs in your area, please contact the McDonald s Service Center at (877)

27 Special Enrollment OTHER IMPORTANT ENROLLMENT INFORMATION (Applies to All Eligible Employees) You and/or your Dependents are eligible for Special Enrollment if the following occurs: Loss of Other Coverage: An Employee or Dependent who is eligible for enrollment under the Plan but is not enrolled may enroll if each of the following conditions is met: When you declined enrollment for yourself or your Dependent, either: you or your Dependent had COBRA continuation coverage under another health plan and that COBRA coverage has now been exhausted; or you or your Dependent had coverage under another health plan (other than through COBRA) and that coverage terminated as a result of loss of eligibility (due to legal separation, divorce or termination of domestic partnership, death, loss of dependent status, termination of employment or reduction in hours of employment) or because employer contributions to that plan were terminated. You enroll yourself and/or your Dependents in the Plan not later than 60* days after the date the COBRA coverage was exhausted or other health plan coverage was terminated. If you or your Dependents lost the other coverage due to failure to pay premiums or for cause (such as making a fraudulent claim), the above special enrollment rights do not apply. Certain Special Enrollment Situations: You or your Dependent(s) may be eligible for Special Enrollment under the Plan due to the following life event change situations: If you are covered under the Plan and a person becomes your Dependent through marriage, meeting the requirements for domestic partnership, birth, adoption or placement for adoption after you enroll in the Plan, such Dependent and/or your Spouse or Domestic Partner may enroll in the Plan during the Special Enrollment Period described below. If you are eligible to be enrolled in the Plan but are not enrolled and a person becomes your Dependent, you, your Spouse or Domestic Partner and/or the Dependent child(ren) may enroll in the Plan during a Special Enrollment Period. You and/or your eligible Dependents who are not enrolled in the Plan may enroll during a Special Enrollment Period under the following situations: You or your Dependent s Medicaid or state Child Health Insurance Program (CHIP) coverage is terminated due to loss of eligibility, or You or your Dependent(s) become eligible for a premium assistance subsidy under Medicaid or CHIP. For Special Enrollments due to marriage, domestic partnership, birth or adoption, the Special Enrollment Period is the 60- day* period beginning on the date of the marriage, meeting the requirements for domestic partnership, birth, adoption, or placement for adoption. This 60*-day period does not apply if you already have Employee & Children or Family coverage and you are adding a Dependent child(ren). For example, if you already have Family coverage and you want to add your newborn, the 60-day* period will not apply. However, the waiver of the enrollment period adding Dependent children may not apply for certain HMOs. For Special Enrollments due to eligibility for a premium subsidy under Medicaid or CHIP, the Special Enrollment Period is 60 days from the date of eligibility for the subsidy. For Special Enrollments due to termination of eligibility for Medicaid or CHIP coverage, the Special Enrollment Period is 60 days from the date of the loss of the Medicaid or CHIP coverage. For Domestic Partners, the 60-day* period begins on the date you and your Domestic Partner have met the requirements for a domestic partnership under the Plan. 24

28 Coverage for any individual enrolled during a Special Enrollment Period becomes effective: In the case of (i) marriage or completion of domestic partnership requirements, (ii) loss of coverage under Medicaid or CHIP or (iii) eligibility for a Medicaid or CHIP subsidy, on the first day of the first month beginning after the date of the special enrollment event (i.e., the date of marriage, etc.) In the case of a Dependent s birth or adoption, as of the date of birth, adoption or placement for adoption. Premiums for marriage, domestic partnership, and CHIP or Medicaid eligibility Special Enrollments will begin on the first day of the month for which coverage begins. For Special Enrollments for birth, adoption or placement for adoption, premiums will begin on the first day of the month in which the birth, etc. occurs. For example, if you have a baby on April 15 th, your premium would start April 1 st and the coverage would start on April 15 th. If you and/or your Dependents are eligible to enroll in a Special Enrollment Period, you may change Plan options at that time (for example, from Silver Plan to Bronze Plan.) *The 60-day period is 31 days for certain HMOs and other Special Enrollment Period requirements may vary among HMOs. Contact your HMO directly for their Special Enrollment Period requirements. Who Pays for Coverage? McDonald's shares the cost of providing Medical and Dental Plan coverage with you. Your cost depends on: Your job class; The level of coverage you elect (i.e., Employee Only, Employee & Spouse or Domestic Partner, Employee & Child(ren), Family with Spouse or Domestic Partner); and The Plan option that you choose. You must pay the entire cost of the Vision Supplement Plan. The cost of coverage can change periodically, and McDonald's will tell you these costs. You will be told of any premium changes during annual enrollment. If you change job class during the Calendar Year, your premium will not change until the next Calendar Year. All of your Plan contributions are made on a pre-tax basis, unless you are on an unpaid leave of absence or long term disability or to the extent that your premium covers a Domestic Partner. In that case, monthly premium payments are made on an aftertax basis unless your Domestic Partner is your dependent for tax purposes. The Plan Administrator has the discretion to impose surcharges or credits to your premiums, provided those surcharges or credits comply with applicable law and are applied in a uniform and nondiscriminatory manner according to federal law. Special Tax Rules If You Cover a Domestic Partner If you cover a Domestic Partner, the portion of your premium that covers your Domestic Partner and your Domestic Partner s children who do not qualify as your dependent under federal tax rules must be made on an after-tax basis. Also, the amount that McDonald s pays towards your family s premium is a nonqualified fringe benefit for federal tax purposes. This means that you must pay taxes on the amount that McDonald s pays. However, if you complete a Dependent Tax Certification Form to certify the family members that qualify as your Dependents for federal income tax purposes, your premiums for the coverage of those family members will be taken pre-tax, and the McDonald s-paid portion of their coverage will not be treated as taxable income to you. The Certification Form is available from the About Me site via Access MCD or by calling the McDonald s Service Center at (877) Life Event Changes Because pre-tax dollars are used for Plan contributions, the IRS requires that changes in elections for these contributions be made only on an annual basis (effective January 1 st ) unless you have one of the following qualifying life event changes: Marriage, divorce or annulment. For Domestic Partners, meeting the requirements for a domestic partnership under the Plan or termination of that domestic partnership.* 25

29 Death of Spouse, Domestic Partner or Dependent child.* Birth, adoption or placement for adoption of a Dependent child.* Beginning or termination of employment for you, your Spouse or Domestic Partner or your Dependent child.* Change in employment-related eligibility for the Plan or another health plan by you, your Spouse or Domestic Partner or your Dependent child.* Change in eligibility status of your Spouse or Domestic Partner or your Dependent child under the Plan or another health plan.* Beginning or returning from an unpaid leave of absence by you, your Spouse or Domestic Partner or Dependent child.* (See also the Continuation of Coverage While on Leave section.) Strike or lockout involving you, your Spouse or Domestic Partner or your Dependent child.* You, your Spouse or Domestic Partner or your Dependent child becomes entitled to or loses coverage under Medicare, Medicaid or any similar coverage that is permitted under the IRS life event rules. You have a reduction in hours and you and your covered family members are eligible for and intend to enroll in another health plan that provides minimum essential coverage. In that case, you must notify the McDonald s Service Center in writing that you intend to have the other coverage in place immediately after your coverage under the Plan ends. Your Dependent child s coverage under a Qualified Medical Child Support Order. Loss of coverage under another health plan that qualifies you, your Spouse or Domestic Partner or your Dependent child for Special Enrollment under the Plan or another health plan. (See Special Enrollment above.) Certain significant increases or decreases in cost of a health, vision supplement or dental option under the Plan as determined by the Plan Administrator. Significant decrease in coverage provided under a health, vision supplement or dental option under the Plan or another health plan, as determined by the Plan Administrator. Your change in residence due to a job transfer that is at least 30 miles from your previous job location, if the change in location causes you to lose coverage under an HMO/DHMO under the Plan. Change in election under another employer s medical, dental or vision supplement plan if (i) that change is permissible under the IRS life event change rules or (ii) the other plan has a different enrollment period. In either event, the change in election under this Plan must be consistent with and correspond to the change in election under the other plan. *Your change of election must be consistent with the life event change. Changes marked with an * are allowed only if the life event change causes you, your Spouse or Domestic Partner or your Dependent child(ren) to lose or gain eligibility for coverage under the Plan or another health plan. You must notify the McDonald s Service Center in writing within 60* days of the date of your qualifying life event change. Your change of election will be effective as of the first day of the month following your qualifying life event change. If your change of election is birth, adoption or placement for adoption of a Dependent child, see Certain Life Event Changes under the Special Enrollment rules above for the effective date of that coverage. If you and/or your Dependents are eligible to enroll in the Plan due to a life event change, you may change Plan options at that time (for example, from Gold Plan to Silver Plan.) *The 60-day period is 31 days for certain HMOs. Qualified Medical Child Support Orders In addition to the above enrollment provisions, the Plan will comply with the provisions of any Qualified Medical Child Support Order ( QMCSO ) to the extent required under Section 609 of the Employee Retirement Income Security Act. For information on the Plan procedures for Qualified Medical Child Support Orders, contact the McDonald s Service Center. You may request a description of the Plan s QMCSO procedures from the McDonald s Service Center free of charge. You and your Dependent(s) will be enrolled in the Gold, Silver or Bronze Plan that is indicated on the QMCSO. If a choice of Medical Plan is not indicated on the QMCSO, you and your Dependent(s) will be enrolled in the Silver Plan unless you elect the Gold or Bronze Plan. 26

30 MEDICAL PLAN OPTIONS A Choice Between Three Plans You have the choice between three PPO Plans: Gold, Silver and Bronze. It is important that you understand how benefits are paid under all three Medical Plans. Then you can choose the Plan that best serves your needs. Refer to the Medical Plan Highlights section for a summary of the Medical Plan choices. All three Plans are designed to encourage you to use innetwork Preferred Provider Organization ( PPO ) services. The PPO for the Medical Plan is offered through the expansive PPO network of Providers that have entered into an agreement with BCBSIL to participate in the network. The BCBSIL PPO network contracts with certain Providers and gives covered Employees and their covered Dependents medical services at negotiated rates. How Your Health Reimbursement Account Works All three Plans include a health reimbursement account (HRA). McDonald s makes a contribution to your HRA for the year, but the amount of that contribution depends on the Gold, Silver or Bronze Plan that you choose, whether or not you are a Benefits-Eligible Crew Employee and the coverage level that you choose. You use the HRA to pay for your initial Covered Expenses incurred in the Calendar Year. You have access to the full amount in your HRA at the beginning of the Calendar Year or when you first enter the Plan. If you do not use the full amount in your HRA in the Calendar Year, the remainder can be rolled over to the next Calendar Year, up to a maximum of a $500 rollover ($1,000 rollover for 2 or more Covered Persons) even if you switch from one Plan to another. The maximum rollover amount that you can have in your HRA at any time is $500 ($1,000 for 2 or more Covered Persons.) The HRA is used first to satisfy your Plan Deductible. It can only be used for Covered Expenses under the Plan and cannot be used for Prescription Drug expenses. If you are eligible for a Healthcare Spending Account, certain other medical expenses and your Coinsurance amount may be reimbursed through that Account. When you are no longer covered under the Medical Plan any remainder in your HRA will be returned to the Medical Plan funds. You will no longer have access to those dollars even if you should elect to participate in the Medical Plan again at a later date. How Your Gold, Silver or Bronze Plan Works McDonald s makes a contribution to your Plan HRA for the Calendar Year. Your HRA is used first to satisfy your annual Deductible. Once you meet your annual Deductible, the Plan pays a Coinsurance amount (65%-80%, depending on the Plan you re enrolled in) of remaining Covered Expenses if you use an in-network Hospital or Provider. If you use an out-of-network Hospital or Provider, the Coinsurance amount is reduced to 50% of the Reasonable and Customary (R&C) amount charged for the service. This Coinsurance amount applies until you reach your Outof-Pocket Maximum. Using a PPO Hospital (Inpatient/Outpatient) or Provider If you reside within a PPO network area and do not use a PPO Hospital and/or Provider, your benefits will be reduced, your Out-of-Pocket Maximum increases and payment will be based on Reasonable and Customary charges. This also includes an eligible Dependent attending school away from home. In general, you reside within a PPO network area if you reside within a 20-mile drive of a PPO Hospital or Provider. 27

31 If an Employee or a Dependent does not live within a PPO network area, has an Emergency or is out of town traveling, the benefit reduction for using an out-of-network Hospital or Provider will not apply. (See Emergency" in the Glossary.) Note: Due to insufficient network Provider access, the benefit reduction will not be assessed for the following out-ofnetwork services*: occupational, speech and physical therapy, optometrist, chiropractor, ambulatory surgical center, oral surgery, ambulance services, skilled nursing facilities, home health care, nutritionists/dieticians, hospice care and durable medical equipment/prosthetics. Further, while you are receiving treatment at a PPO Hospital, charges from an out-of network Provider for anesthesiology, laboratory services, pathology, radiology, neonatology or any other services will be considered at the PPO in-network level of benefits*. However, any follow-up care from the out-of-network Provider will be considered at the out-of network level of benefits. Providers are added to or removed from the network throughout the year, so verify that your Provider is in the network before you receive services. Participating Providers in the BCBSIL PPO network can be found by calling BCBSIL at (800) , or by accessing the Internet: The directory of participating Providers in the PPO network is provided to you in electronic format. If you would like a paper or hard copy of the network Hospitals or Providers in your area as a separate document free of charge, contact BCBSIL. * This means, for example, that if you are in the Gold Plan, those services will be paid at 80% of Reasonable and Customary (R&C) charges instead of at 50%. PPO Price Calculations The Blue Cross and Blue Shield Plans contract with PPO Network Providers for covered services rendered to Covered Persons. Those contracts include the terms under which the Providers will be reimbursed for those services. When calculating McDonald s and the Covered Person s liability for those services, the negotiated price can be determined by the one of the following methods: a. the actual price, or b. an estimated price determined by projections based on historical experience, or c. an average price determined by provider groupings In situations where an estimated or average price is used, the actual payment to the provider may be greater or less than the estimated or average price. However, the amount paid by McDonald s and the Covered Person is the final price. 28

32 MEDICAL BENEFITS Deductibles A Deductible is the money you must spend each Calendar Year for Covered Expenses before the Plan begins paying benefits. The amount of your Deductible for each Calendar Year depends on whether you selected the Gold, Silver or Bronze Plan and whether you select Employee Only, Employee & Spouse or Domestic Partner, Employee & Child(ren), or Family with Spouse or Domestic Partner coverage. For example, the Employee Only annual Deductible under the Gold Plan is $1,000. If you have coverage for 2 or more Covered Persons under the Gold Plan (for example, Family with Spouse coverage), the annual Deductible for your family is $2,000. See the Medical Plan Highlights section for a complete list of Plan Deductible amounts. If you elect coverage for 2 or more Covered Persons (for example, Family with Domestic Partner coverage), you meet the Deductible for that coverage when the family members' Covered Expenses, added together, reach that Deductible. However, no single family member gets credit for more than the individual Deductible for one Covered Person. In other words, once a covered family member has met the Deductible for one Covered Person for a Calendar Year, none of the Covered Expenses he or she incurs after that count toward meeting the family's Deductible for 2 or more Covered Persons for that Calendar Year. The following expenses do not count toward your annual Deductible: Hospitalization non-notification penalties. $100/$200 Emergency room Copay. Prescription Drugs covered under CVS Caremark. Non-covered expenses. Charges in excess of the R&C cost. Coinsurance When the Plan pays for Medical, Mental Health and Substance Abuse and Prescription Drug (including Specialty Drug) expenses at a specified percent, you have to pay the remaining percent. For example, if you are covered under the Gold Plan, the Plan pays in-network Covered Expenses at 80% and you have to pay the remaining 20%. Similarly, if you use an out-ofnetwork Physician or Provider, the Plan pays Covered Expenses at 50% of Reasonable & Customary ( R&C ) and you have to pay the rest. The amount that you have to pay is your Coinsurance amount. Out-of-Pocket Maximum When your Coinsurance amount, any Copays and the amounts you paid toward your Deductible for an individual/family reaches a certain level, Covered Expenses are paid by the Plan at 100% for the remainder of the Calendar Year. That level is your Out-of-Pocket Maximum. See the Medical Plan Highlights section for a list of Out-of-Pocket Maximums. Note that your Prescription Drug (including Specialty) Coinsurance/Copays apply only to your in-network Out-of-Pocket Maximum, not your out-of-network Out-of-Pocket Maximum. The following expenses do not count toward your Out-of-Pocket Maximum: Hospitalization non-notification penalties. Prescription Drug retail maintenance penalties, Copays for using out-of-network Pharmacies and amounts you pay for brand-name drugs when a generic is available. Non-covered expenses (including non-covered Mental Health/Substance Abuse or Prescription Drug expenses). Charges in excess of the R&C cost. 29

33 Covered Expenses Under the Gold, Silver and Bronze Plans, Covered Expenses are the actual cost of R&C charges for Medically Necessary services and supplies that are covered by the Plan. When you use in-network Providers, all services are charged at negotiated rates. You don t have to worry about paying charges over the R&C amount. You are responsible, however, for charges over the R&C costs if you seek care from out-of-network Providers. (See Reasonable and Customary/R&C in the Glossary.) In addition, the service or supply must be: Medically Necessary (defined in the Glossary); Recommended and approved by the attending Physician unless noted otherwise in the services listed below; and Not determined to be Experimental/Investigational. Covered expenses also include the actual cost of R&C charges for certain routine or preventive services and supplies, but only if specifically described in the Plan. Certain Covered Expenses are subject to special limits, as noted below. The following is a list of the Covered Expenses under the Plan. In general, Covered Expenses are subject to your Deductible and Coinsurance, unless otherwise indicated. A list of non-covered expenses can be found in the Non-Covered Expenses section. However, it is important to note that the following list includes many of the medical expenses that are covered by the Plan. Although extensive, the list is by no means comprehensive. It is possible to have Covered Expenses that are not listed here. Also, note that all Covered Expenses are subject to BCBSIL policies, available at In addition, you might find a particular medical treatment is covered under the Plan only to a certain point. Rather than establish a specific number of times you can receive treatment, each case is reviewed individually by BCBSIL s medical staff. For example, you might have a chronic condition that can be helped through treatment, but only to a point. If it has been determined that your condition has reached a maintenance mode, any further expenses for the same treatment can be denied. Examples of this are chiropractic services, and therapies such as physical, eye and speech. If you have questions or concerns about Covered Expenses, whether they are included in the list below or not, contact BCBSIL at (800) Ambulance - Transportation to the nearest Hospital qualified to provide treatment and necessary care when the patient s condition makes the use of other methods of transportation life threatening, or when being transported from the scene of an accident. Ambulatory Surgical Center Services - Services given in connection with a surgical procedure. Anesthetics - Anesthetics and charges associated with administering them. General anesthesia (IV section) is covered when used and charged by a Physician or Dentist for a covered surgical procedure at R&C charges. Local anesthesia is included in the benefits for surgery and will not be considered separately. Assistant Surgeon - A Physician with the designation M.D., D.O., D.M.D., or D.P.M. Coverage is available depending on the procedure performed. The assistant surgeon s covered charge will not exceed 20% of the surgeon s Reasonable and Customary allowance. Attention Deficit Disorder - Treatment for Attention Deficit Disorder when treatment is Medically Necessary and not for educational purposes. Treatment for Attention Deficit Disorder that is mental health related (i.e., psychotherapy) may be covered through ComPsych. Birth Center Services - Room and board charged by the birth center, other services and supplies, anesthetics and charges associated with administering them. Birth Control - Covered as a preventive care benefit at 100% with no Deductible when delivered by a network Provider (45% for out-of-network Providers) for all FDA-approved contraceptive methods, certain sterilization procedures and patient education and counseling for women as prescribed by a Physician in accordance with the guidelines of the Health Resources and Services Administration. See also Preventive Care Benefits below. Chemotherapy Treatment - Chemotherapy treatment including materials and the services of a technician. 30

34 Chiropractic Services - Medically Necessary chiropractic treatment. After 20 sessions, BCBSIL may request records to verify Medical Necessity. If clinical circumstances verify the need, additional treatments may be authorized. Emergency - Emergency room services for Emergency Services and Emergency Diagnosis as defined in the Glossary. If you receive emergency room treatment and you are not admitted to the Hospital, you will be required to pay a $100 emergency room Copay for your first visit in a Calendar Year ($200 for subsequent visits by the same Covered Person in that Calendar Year) in addition to any Deductible and/or Coinsurance. Emergency Transportation Services - By professional ambulance, other than air ambulance, to and from a Hospital. By regularly scheduled airline, railroad or air ambulance to the nearest Hospital qualified to give the required treatment. Genetic Testing - Covered if Medically Necessary for treatment of a medical condition or pregnancy. Growth Hormones - Covered through the Specialty Medication Program, subject to meeting specific medical criteria based on age and diagnosis. See Specialty Medication Program in the Prescription Drug Benefit section. A pre-determination of benefits is required to determine Medical Necessity. Hearing Aids - Charges for: One hearing aid per Covered Person every 36 months, subject to your Deductible and Coinsurance at the in-network level. Exam and fittings for hearing aids. Home Healthcare after Hospital Confinement - Charges for Home Healthcare Services and Supplies are covered only for Medically Necessary care and treatment of an Injury or Sickness when Hospital or Skilled Nursing Facility confinement would otherwise be required. The diagnosis, care and treatment must be ordered by the attending Physician and be contained in a Home Healthcare Plan. Home Healthcare Services and Supplies include temporary or part-time nursing care by a qualified Provider (i.e., R.N., L.P.N., and L.V.N.) and supervised by a registered nurse (R.N.); temporary or part-time care by a home health aide; Physical Therapy; Occupational Therapy; and Speech Therapy, subject to any limitations of the Plan. A home healthcare visit will be considered a periodic visit by a nurse, therapist or home health care aide. (See Skilled Nursing Service in the Glossary.) The Home Healthcare Services must be for the same condition as the Hospital confinement. A maximum of 80 visits for Home Healthcare Services is covered per Calendar Year. Hospice Care Services - Hospice Care Services and Supplies, as well as part-time nursing care by or supervised by a registered nurse (R.N.), counseling for the patient and the patient s immediate family (by a licensed Social Worker or a licensed pastoral counselor) and bereavement counseling. Services for the patient must be given in an inpatient Hospice Unit or in the patient s home. The Physician must certify that the patient is terminally ill with 6 months or less to live and place the patient under a Hospice Care Plan. Covered Expenses include bereavement counseling only for the patient s immediate family. Services must be given by a licensed Social Worker or a licensed pastoral counselor. All of the following will apply: The Physician must certify that the patient is terminally ill with 6 months or less to live. Payment is limited to a total of 15 visits per family per terminally ill patient. Services must be given in an inpatient Hospice Unit or in the patient s home. Services must be given within 6 months of the patient s death. Hospital Services - Covered Expenses include full room and board charges for a ward, semi-private room or an Intensive Care Unit. For a private room, charges up to the Hospital s regular daily charge for a semi-private room will be counted as Covered Expenses. Covered Expenses also include other services and supplies associated with the Hospital stay. Infertility Testing - Initial consultation, estradiol assay (initial only), lab and drug interpretation which are included in the office visit, initial ultrasound (if diagnostic only) and interpretation if not directly related to artificial insemination, in vitro fertilization or G.I.F.T., and history and physical, which would also be included in the initial office visits. Tests or procedures to diagnose the cause of infertility are Medically Necessary, as are surgical procedures to treat the cause of infertility. A diagnostic workup for females includes: (1) sedimentation rate (ESR); (2) antisperm antibody testing; (3) laparoscopy and/or 31

35 hysteroscopy; (4) hysterosalpingogram; (5) urinalysis; (6) serology; (7) cultures; and (8) CBC. Maternity Care - Charges for the care and treatment of Pregnancy are covered the same as any other illness. IMPORTANT NOTICE: Group health plans and health insurance issuers 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 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 her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a Provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). If your stay extends beyond 48 hours (or 96 hours), you must notify BCBSIL prior to the commencement of the extended stay or a penalty will be imposed. See the Precertification for Hospitalization section. Medical Supplies - Covered Expenses include the following: Prescription Drugs and medicines administered and/or dispensed from a Hospital or Physician s office. Specialty Medications must go through Specialty Rx. Surgical supplies (e.g., bandages and dressings). An appliance which replaces a body organ or part or helps an impaired one to work (e.g., artificial limb or eye). Oxygen and charges for its administration (this includes rental of required equipment). Rental of a wheelchair or Hospital-type bed up to the purchase price only or the monthly maintenance fees, whichever is applicable. Rental of a device to help breathing up to the purchase price only or the monthly maintenance fees, whichever is applicable. Blood or blood plasma. Continuous Passive Motion (CPM) devices (but only when used in rehabilitation following total knee replacement and Anterior Cruciate Ligament (ACL) repair.) Orthotics (custom molded foot inserts), one pair per lifetime. A replacement is covered if the current orthotic is no longer of use due to the person experiencing a physical change (i.e., foot surgery, weight loss). Coverage is not available if a replacement is due to wear and tear. Must be prescribed by a Physician or podiatrist. Covered Expenses will only include the first purchase of a particular piece of equipment and will include replacements only when the equipment is not repairable. Reasonable charges for maintenance and repair of purchased pieces of medical equipment are Covered Expenses. A rental trial period to evaluate the effectiveness of an item of medical equipment is recommended. Nursing Services - Services of a registered nurse (R.N.) or licensed practical nurse (L.P.N.) or licensed vocational nurse (L.V.N.) who is not a member of your immediate family or does not reside in your home, acting within the scope of such license or certification. The services have to be Medically Necessary and not custodial in nature, and must be recommended and approved by a Physician. (See Skilled Nursing Services in the Glossary.) The only expenses covered for nursing care given in the home are those shown under Home Healthcare After Hospital Confinement above. (See Custodial Care in the Glossary.) Nutritionist Visits/Nutritional Counseling - Visits to a nutritionist are covered at 100% for both in- and out-of-network Providers, not subject to your Deductible, up to 3 visits per Calendar Year per Covered Person. Additional nutritional counseling will be covered only if Medically Necessary for certain illnesses and if performed at a facility under the supervision of a Physician. Your Deductible and Coinsurance will apply. Nutritional counseling may also be covered under the Weight Loss Program for Morbid Obesity or under the Mental Health Program for certain eating disorders. See Weight Loss Programs and Mental Health and Substance Abuse Program. Nutritional Supplements - Covered only when such supplements are the only form of nutrition. These are not covered when being used to supplement regular meals. Obesity - Covered Expenses include the following: Gastric bypass with anastomosis, small intestine. 32

36 Gastric stapling. Gastroplasty vertical and horizontal banded gastroplasty. Biliopancreatic diversion. Complications arising from bariatric surgery (e.g., obstruction). Expenses are covered only if you have a BMI of 30 or higher and have participated in a supervised weight loss program for at least 6 months. Obesity treatment must occur within 6 months after ending the supervised weight loss program. Only one surgical procedure for weight loss per Lifetime per individual is covered. This limit does not apply to surgery for excess skin removal after weight loss surgery. Occupational Therapy/Physical Therapy - ADULT - Medically Necessary Occupational Therapy/physical therapy. Covered expenses include the following: Physician office visit - Physician must order the Occupational Therapy/physical therapy. In cases involving case management, a treatment plan is required. Physician must monitor the course of therapy. Services must be performed by a registered physical therapist and they must submit progress reports at stated intervals. After 20 sessions per occurrence, BCBSIL may request records to verify Medical Necessity and to determine that the patient is making a recovery and resuming independence. Additional treatments may be authorized if clinical circumstances exist. See Chiropractic Services above. Continuous Passive Motion devices are considered Medically Necessary when used in rehabilitation following total knee replacement and Anterior Cruciate Ligament repair (ACL). Case Management will review Medical Necessity and therapeutic benefits in cases of chronic neurological disease. Outpatient physical therapy services will only be covered for an accidental Injury, fracture, and orthopedic surgery or for a chronic disease which causes pain or loss of function (e.g., arthritis). See Occupational Therapy in the Glossary. Occupational Therapy/ Physical Therapy - CHILD - Covered expenses include the following: For acute events, the same guidelines as for adults apply (see above). For chronic disorders, physical therapy should be used as a short term intervention. A home program should be an integral part of any physical therapy. After 20 sessions per occurrence, BCBSIL may request records to verify Medical Necessity and to determine that the patient is making a recovery and resuming independence. Additional treatments may be authorized if clinical circumstances exist. Physiotherapy - Services of a physician therapist. Physician s Services - Services for surgical procedures as well as other medical care and treatment. These can be services such as Hospital, office or home visits, emergency room treatment or second surgical opinions. Physician s services do not include routine office visits, unless otherwise indicated in the Plan. Pre-Admission Testing - Covered for pre-admission testing for surgical admissions or procedures. Duplicate tests, when other such tests were performed within 7 days by another professional or facility, are not considered Medically Necessary. Preventive Care Benefits - Covered expenses for each Covered Person include the following preventive care benefits as required by regulations under the Affordable Care Act ( ACA ): 100% in- and out-of-network, with no Deductible for an annual physical exam fee, as well as for the following preventive care benefits: Preventive care services as recommended by the United States Preventive Services Task Force that have a rating of A or B. Routine vaccinations/immunizations as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention Recommended Immunization Schedules. Preventive care and screening recommendations and guidelines supported by the Health Research and Services Administration for infants, children, adolescents and women. 33

37 The following preventive screenings to the extent that the preventive services listed below are more frequent than under the above recommendations: o o o Mammograms (one per Calendar Year). Well Baby care. See Well Baby Care below. Colonoscopy screenings (one every five Calendar Years). To find out if your preventive care service is covered under the above guidelines, check with BCBSIL. If you use an out-of-network Provider, these preventive care benefits are based on Reasonable and Customary charges. If you have an HRA, these preventive care benefits will not reduce the amount in your Account. For purposes of the Plan, immunizations include only those injections that are given to protect the Covered Person from specific diseases and do not include injections that are given to a Covered Person as treatment for a specifically diagnosed illness or disease. Psychologist s Services - Psychological testing and psychotherapy. Radiation Therapy - Covered expenses include radiation treatment with radioactive substances, as well as the materials and services of technicians. Reconstructive Surgery Following Mastectomy - Covered Expenses include the services and supplies for the following surgical reconstructive procedures incurred with respect to a mastectomy: Reconstruction of the breast on which the mastectomy has been performed. Surgery and reconstruction of the other breast to produce a symmetrical appearance. Prostheses and physical complications for all stages of the mastectomy, including lymphedemas. As is the case with all other Covered Expenses, the benefits for such reconstructive surgery are subject to the Deductible and Coinsurance provisions of the Plan. Skilled Nursing Facility Care after Hospital Confinement - Room and board, other services and supplies for the first 120 days of confinement each Calendar Year. Charges are counted as Covered Expenses up to the Skilled Nursing Facility s regular charge for a semi-private room. A Physician must supervise the care. (See Skilled Nursing Facility in the Glossary.) Sleep Apnea Syndromes - Expenses for sleep apnea syndrome when breathing stops recurrently during sleep for periods long enough to cause measurable blood deoxygenation. Coverage includes Medically Necessary diagnostic testing and treatment. Snoring in itself is not considered a medical disorder. Social Worker s Services - Services of a Social Worker in a state-licensed facility (unless occurring in states where no government licensing or certification exists). Mental Health assessment and treatment by a Social Worker do not have to be recommended and approved by a Physician. (See Social Worker in the Glossary.) Speech Therapy - Speech and language therapy for adults prescribed by a Physician to restore speech loss resulting from: Cerebrovascular accident. Cranial trauma or surgery. Vocal cord surgery. Cases where improvement cannot be maintained (e.g., multiple sclerosis), or diseases where exacerbation can cause a regression are not considered Medically Necessary. After 20 sessions, BCBSIL may request records to verify Medical Necessity and to determine that the patient is making recovery and resuming independence. If clinical circumstances verify the need, additional treatments may be authorized. Also, speech and language therapy are covered for children under the age of 19. Speech and language therapy for the following conditions will be covered up to 30 visits per Calendar Year. Covered conditions include (but not exclusively) 34

38 disorders such as developmental delay, cleft lip/palate, autism, cystic fibrosis, cerebral palsy, muscular dystrophy, apraxia, dyspraxia, attention deficit/hyperactivity disorder, attention deficit disorder, down syndrome or dyslexia. The number of sessions covered is based on the individual child s medical need. After 20 sessions, BCBSIL may request records to verify Medical Necessity. If clinical circumstances verify the need, additional treatments may be authorized. Surgical Assistant Services - Coverage is available for a non-physician depending on the procedure performed. The Surgical Assistant s covered charges will not exceed 15% of the Surgeon s R&C allowance. (See Surgical Assistant in the Glossary.) Ultrasound - Charges for one routine ultrasound during the course of a Pregnancy will be covered by the Plan. Ultrasound means the use of special equipment to produce an image or a photograph of an organ or a tissue. Vision Exam - Services for one routine eye exam per Covered Person per Calendar Year. If you go to an ophthalmologist for your vision exam, you should use a Provider who participates in the BCBSIL PPO network. If you do not use an ophthalmologist who participates in the BCBSIL PPO network, your vision exam will be paid at the out-of-network level based on Reasonable and Customary charges. If you go to an optometrist for your vision exam, due to insufficient network Provider access for optometrists, your benefits will be paid at the in-network level based on R&C charges. Vision Therapy - Vision therapy is considered to be Medically Necessary only if recommended and performed by an optometrist or ophthalmologist for the following diagnosis: Children - The child must have resultant convergency insufficiency or intermittent exotropia or small vertical muscle deviation. Limited to 30 sessions per child per lifetime. Adults - For adults who have a disturbance of binocular vision which has been corrected (e.g., diabetic eye muscle palsy or trauma to the eye socket) and have resultant convergency insufficiency or intermittent exotropia or small vertical muscle deviation. Limited to 10 sessions per adult per lifetime. Constant Esotropia and Constant Exotropia and orthoptic vision therapy for treatment of reading or learning disabilities are NOT considered Medically Necessary. Weight Loss Programs - Office visit and lab expenses for a supervised weight loss program if for the diagnosis of obesity, as provided by the Provider of the program, if the following criteria is met: The weight loss program must be supervised by medical personnel (e.g., Physician or dietician) and include a plan that contains the following core elements: An initial assessment of nutrition and lifestyle assessment. Ongoing nutrition counseling and goal setting. Information regarding managing lifestyle factors that affect diet and goals. Follow-up visits to monitor progress managing diet and exercise. Expenses are paid at 100%, with no Deductible, whether provided through an in-network or out-of network Provider, up to a lifetime maximum of 25 visits per individual. Coverage excludes health club memberships, personal trainers, special food, weight loss program fees, supplements and/or formulas, equipment or workout clothes. If you have questions with respect to coverage call (800) In addition, any Mental Health needs associated with weight loss should be coordinated through ComPsych under the Program. Covered expenses for a Physician office visit with a diagnosis of an eating disorder are considered under Mental Health benefits. Covered Expenses from a Physician with a diagnosis of morbid obesity are considered expenses under the Weight Loss Program. To receive this benefit, you must contact BCBSIL at (800) to precertify your care. Well Baby Care - Initial Hospital confinement charges for your newborn Dependent s nursery care, Hospital services and supplies, surgeon s charge for circumcision and Physician charge for Hospital visits. These charges are subject to your Deductible and Coinsurance. In addition, the Plan will cover the well baby care expenses listed under Preventive Care Benefits above. 35

39 X-rays and Laboratory Tests - For routine tests, diagnosis or treatment. If you have your lab tests processed and billed by Quest Diagnostics, eligible expenses will be paid at 100% and are not subject to your Deductible and Coinsurance. To take advantage of the Quest Diagnostics benefit, you must inform your Provider that you want to use Quest Diagnostics for your lab work processing and that Quest Diagnostics, not your Provider, must bill BCBSIL for the lab work. You can locate the nearest Quest Diagnostics facility by calling (800) (A list of non-covered expenses can be found in the Non-Covered Expenses section.) 36

40 MENTAL HEALTH AND SUBSTANCE ABUSE PROGRAM Under the Gold, Silver and Bronze Plans, eligible Mental Health and Substance Abuse expenses are covered through a program managed through GuidanceResources, by ComPsych. This program offers you and your eligible Dependents a higher level of benefits if you use one of the Providers available through this program. When you use a GuidanceResources network Provider, in general, your benefit level is higher and no claim forms are required. All expenses, whether Inpatient or Outpatient, must be Medically Necessary to be covered under the Mental Health and Substance Abuse Program. Inpatient Expenses If you use a GuidanceResources network Provider, the Plan pays for the GuidanceResources contracted charges for Inpatient treatment for Mental Health and Substance Abuse according to the Coinsurance level of your chosen Gold, Silver or Bronze Plan. If you do not use a GuidanceResources network Provider, the R&C charges for Inpatient treatment will be payable at 50%. In either case, the charges are subject to and applied toward your Medical Deductible and apply to your Medical Plan Out-of-Pocket Maximum. Note that if you use a Substance Abuse Treatment Center, the above benefit provisions will apply to expenses for room and board, as well as other services and supplies, up to the Treatment Center s regular daily charge for a semi-private room. Inpatient Non-Notification Penalty You must notify GuidanceResources of a scheduled inpatient admission date to precertify your care before the start of all non-emergency Inpatient confinements for you or a Dependent to avoid paying a $250 non-notification penalty. This penalty does not apply to the Deductible or Out-of-Pocket Maximum. If you do not notify GuidanceResources, you will be responsible for the non-notification penalty. In the case of an Emergency Inpatient admission, you (or a family member or the Provider) must notify GuidanceResources within two working days of the date the confinement begins or pay the $250 non-notification penalty. GuidanceResources will send a letter to you confirming you called them. A copy is sent to your Provider and the Hospital. All decisions concerning your healthcare are the responsibility of you and your Provider. If you have notified GuidanceResources as required, your benefits will not be subject to the non-notification penalty even if you and your Provider fail to follow the GuidanceResources recommendation regarding your Inpatient length of stay. Outpatient Expenses If you use a GuidanceResources network Provider and you precertify your care, the Plan pays 100% of the charges for Outpatient treatment for Mental Health and Substance Abuse, subject to a $10 Copay per visit. If you use a GuidanceResources network Provider but do not precertify your care, the Plan pays the same Coinsurance amount as your Medical Plan. If you do not use a GuidanceResources network Provider, the R&C charges for Outpatient treatment for Mental Health and Substance Abuse will be payable at 50%. All Outpatient Expenses are subject to your Medical Deductible (except the $10 Copay if you use a GuidanceResources network provider and you precertify your care) and count toward your Medical Out-of-Pocket Maximum. Treatment for Attention Deficit Disorder that is Mental Health related (i.e., psychotherapy and/or medication management provided by a Mental Health specialist), and not for educational purposes (i.e., provided by a Physician who is not a psychiatrist), is covered through GuidanceResources. Treatment for Attention Deficit Disorder that is medical related is covered as a Medical Plan Covered Expense rather than through GuidanceResources. Accessing the GuidanceResources Network When you need Mental Health or Substance Abuse services, call GuidanceResources at (888) Help is available 24 hours a day 365 days a year. They will assist you in finding a Provider within the GuidanceResources network. Then you call the Provider and set up an appointment. Once you have set up an appointment, you should call GuidanceResources to 37

41 have the appointment(s) with that Provider precertified to make sure you are getting a higher quality of care and highest level of benefits. Once you have exhausted your precertified visits, it is your responsibility to have your Provider contact GuidanceResources to precertify any additional visits. All benefits payable under the Plan for Mental Health and Substance Abuse care are subject to the payment levels and limitations of your chosen Plan. Alternatively, Employees who are eligible for the Employee Resource Connection may find it advantageous to call the Employee Resource Connection at (888) for short-term assistance related to daily living problems. The Employee Resource Connection benefit is available to McDonald s Certified Swing, Primary Maintenance Full-Time and Part-Time Staff and Restaurant Management Employees and their eligible Dependents. Services provided by the Employee Resource Connection are prepaid by McDonald s and free to the Employees and their eligible Dependents. See the Employee Resource Connection section in the SPD. Emergency Care A $100 Copay will be assessed for your first emergency room visit in a Calendar Year unless you are admitted to the Hospital (increased to $200 for subsequent visits in the same Calendar Year.) If you are admitted to the Hospital, the Copay is waived. The Copay is in addition to your Deductible and Coinsurance. As with all other expenses, all Emergency care must be Medically Necessary. Emergency care that is not Medically Necessary will not be reimbursed. See also the In-Patient Non- Notification Penalty section above. Emergency care given by an out-of-network Provider is paid at the in-network level. After the Emergency care has ended, the out-of-network level of benefits applies to any further out-of-network care. How to File a Claim See also the Applying for Benefits section. 38

42 PRESCRIPTION DRUG BENEFIT (CVS Caremark) Under the McDonald s PPO Plans, eligible Prescription Drugs are covered through CVS Caremark. Prescription Drugs are not covered by BCBSIL. This benefit pays for Prescription Drugs ordered in writing by a Physician for treatment of you or your Dependent(s) because of accidental Injury, Sickness, or Pregnancy. This benefit does not cover Prescription Drugs obtained from a Hospital or Physician s office. For a list of non-covered items, see Non-Covered Prescription Drugs in the Non- Covered Expenses section. Participating Pharmacies Many Pharmacies participate in the CVS Caremark Plan. To find a CVS Caremark Pharmacy near you, go to How to Use Your Prescription Drug Plan The amount you pay for your prescription depends on the Plan that you choose, where you fill your prescription and whether you receive a Generic, Preferred Brand or Non-Preferred Brand Drug, as displayed in the chart below. GOLD PLAN SILVER PLAN BRONZE PLAN *30-day supply or less: In-Network Pharmacy CVS Caremark Network Generic: 10% Coinsurance /$10 max Preferred Brand: 20% Coinsurance /$30 max Generic: 20% Coinsurance /$20 max Preferred Brand: 30% Coinsurance /$40 max Generic: 20% Coinsurance /$20 max Preferred Brand: 30% Coinsurance/ $40 max Non-Preferred Brand: 40% Coinsurance/$60 max Non-Preferred Brand: 50% Coinsurance/$70 max Non-Preferred Brand: 50% Coinsurance /$70 max *30-day supply or less: Applies to Out-of- Network Retail Pharmacy NOT in CVS Caremark network or if you do not use your BCBSIL ID card 50% Coinsurance + $5 Copay for Generic & Brand Name Max claim amount allowed: $2, day supply: applies only to CVS Mail Service Program or CVS Retail Pharmacy Generic: 10% Coinsurance /$25 max Preferred Brand: 20% Coinsurance /$75 max Generic: 20% Coinsurance /$50 max Preferred Brand: 30% Coinsurance /$100 max Generic: 20% Coinsurance /$50 max Preferred Brand: 30% Coinsurance /$100 max Non-Preferred Brand: 40% Coinsurance / $150 max Non-Preferred Brand: 50% Coinsurance /$175 max Non-Preferred Brand: 50% Coinsurance /$175 max CVS Specialty Prescription Program: 30 day supply or less $300 Copay *Plus $25 penalty on maintenance drugs after three (3) 30-day refills 39

43 As you can see in the above chart, if you do not use your BCBSIL ID card or you go to a Pharmacy that is not in the CVS Caremark network you will pay a Coinsurance of 50% of the prescription or refill cost after a $5 Copay, plus a $25 penalty for maintenance drugs after the first three refills. The maximum claim amount for these submitted claims is $2,000. You will also not have the advantage of special negotiated prescription rates. You will need to pay the full cost of the prescription and submit a claim form to get reimbursed for your benefit. You can get a CVS Caremark claim form from CVS Caremark at and mail the completed form along with a copy of the bill to CVS Caremark for reimbursement. Based on clinical guidelines, CVS Caremark also places a quantity limit that may be less than the original prescribed amount on select classes of drugs to ensure appropriate drug usage. You must pay 100% for quantities above the limit. On some of those drugs, you may be able to receive a larger quantity than the CVS limit if it is determined to be Medically Necessary through a prior authorization process. Contact CVS Caremark for a list of drugs subject to quantity limits and to request a prior authorization for a larger quantity. CVS Caremark Mail Service You can use any of these options to order a prescription through CVS Caremark Mail Service: Call FastStart at (800) , or Give your Physician s office the toll-free FastStart physician number, (800) , or Obtain a 90-day prescription from your doctor and send it with the mail service order form to CVS Caremark. Obtain the form online at or by calling the McDonald s Service Center. You can refill your mail service prescription by calling CVS Caremark at (866) or through their website 24 hours a day, seven days a week. You can also mail in the order form that comes with your mail prescription. CVS Caremark will mail your prescription to the address you specify within approximately 10 business days of receiving the order. You can request expedited shipping for an additional fee. To register to begin using the online refill service: Go to the website at: Click on New to Caremark.com? Register Now and follow the steps from there. You will need your member ID, which is either the number on your insurance ID card (beginning with the fourth character, i.e., M ) or your Social Security number. You will designate your own username and password for the site. Out-of-Pocket Maximum/Deductible/HRA Funds Your Prescription Drug expenses are combined with your medical expenses for your in-network Out-of-Pocket Maximum. When a Covered Person reaches the in-network or Out-of-Pocket Maximum for their Plan, the Covered Person s Prescription Drugs will be paid at 100%, based on the cost of a Generic Drug, if available. The out-of-network Out-of-Pocket Maximum does not include your Prescription Drug expenses. The Out-of-Pocket Maximum does not include the $5 additional Copay that you pay if you use a Pharmacy that is not in the CVS Caremark network, the additional amount that you pay for a Brand Name Drug when a Generic Drug is available or the $25 penalty if you fill a 30-day supply of a maintenance prescription more than three times at a retail Pharmacy. There is no Prescription Drug Deductible. Your HRA Funds cannot be used for your Prescription Drugs. Generic Drug Program If a Generic Drug is available for your prescription and you choose to use a Brand Name Drug (Preferred or Non-Preferred) instead, you will pay the Coinsurance plus the difference in price between the Generic Drug and the Brand Name Drug, even if the Brand Name Drug is required by your Physician. 40

44 Performance Rx Program The Performance Rx Program is similar to the Generic Drug Program. This program allows for the substitution of less expensive therapeutically equivalent drugs. The program is completely voluntary. If you are given a prescription for a Brand Name Drug but there is an equivalent at a lower cost available, you may choose the equivalent. If you agree to the alternative brand, your pharmacist will call your Physician to authorize the substitution. The alternative may only be substituted for a Brand Name Drug if both you and your Physician agree to the substitution. If you and/or your Physician do not agree to the substitution, you will receive the Brand Name Drug (subject to the Generic Drug Program.) Specialty Medication Program The Specialty Medication Program through CVS Caremark Specialty Pharmacy Services offers certain high-cost, high-tech injectable and oral drugs and supplies for certain serious conditions. Drugs that are in the specialty drug category, including drugs administered in a Physician s office, must be ordered through CVS Caremark. If you get these drugs through a retail Pharmacy, you will not be reimbursed for them. With CVS Caremark Specialty Pharmacy Services, you will: Enjoy convenient, easy ordering of your medication and supplies from one reliable source. Get express delivery to the location of your choice (i.e., home, Physician s office, vacation spot, etc., or medication pickup option at select CVS retail pharmacy locations.) Receive informative care management materials. Have access to pharmacists and other health care professionals to help you stay healthy. Receive potential savings because the Specialty Medication Program offers some of the most competitive pricing available. When you or your Dependent needs specialty pharmaceuticals and/or supplies: You should call CVS Caremark Connect at (800) and identify yourself as a member of a McDonald s Medical Plan. CVS CaremarkConnect representatives are available Monday through Friday, 6:30 a.m. 8 p.m. EST. You will be charged a $300 Copay for each prescription fill. Your Copay amount will be applied toward satisfying the combined Medical and Prescription Drug in-network Out-of- Pocket Maximum. CVS Caremark may change the list of specialty drugs from time to time, adding new drugs to the list or removing drugs that were previously on the list. To check whether a particular specialty drug is on the list, you should call (800) or visit You may receive up to a 30-day supply at a time if prescribed by your Physician. Specialty Guideline Management (SGM) If you are prescribed a specialty drug, you will become part of the SGM program. The SGM program works with you and your Physician to ensure the appropriate utilization of specialty medications. The SGM program reviews clinical records (via discussions with the prescribing Physician) to help ensure effective drug use. The program optimizes outcomes of drug usage and promotes safe, clinically appropriate and cost effective use of specialty medications. Smoking Cessation Prescription Drug Benefit You are eligible for up to 2 courses of treatment annually of smoking cessation prescription drugs (including over-the-counter drugs, generic drugs and brand name drugs without a generic alternative with a prescription) through CVS Caremark at no cost to you. 41

45 BLUE CARE CONNECTION You and your covered Dependents have access to Blue Care Connection services through BCBSIL that provide you with personalized attention, support, online resources and health advocacy. Blue Care Advisor nurses will help you find the right resources, optimize your wellness, make the most of your health care benefits and manage your medical conditions. Here s what s included: Primary Nurse Team A team of nurses at BCBSIL are there to help when you or your covered Dependents are hospitalized or in the emergency room, undergoing complex care such as cancer or a transplant, need home health care, have one of the chronic conditions addressed through the Condition Management Program and more. In situations like these, a Primary Nurse will reach out directly to you and your Providers. Or, you can call them at (800) and ask for the Primary Nurse Team. Your nurse will provide you with individualized, personal help to coordinate the flow of information among your caregivers, work with your Providers, give you education and support and help ensure you are getting the right care for the right cost. The services are completely confidential through BCBSIL. Case Management McDonald s provides a valuable benefit program called Case Management. The program is designed to help patients and their families improve the quality of their lives by providing assistance in managing medical care when patients experience serious, long term healthcare problems. If your condition qualifies for Case Management, you will be contacted by a Case Management nurse to see if you would like to participate in the program. When a catastrophic condition, such as a spinal cord injury, a degenerative sickness, or a neurological paralytic disease occurs, a person may require long term, perhaps lifetime care. After the person s condition is stabilized in the Hospital, he or she might be able to be moved out of the Hospital and into another type of care setting even to his or her home. Case Management occurs in the following situations: The catastrophic Injury or Sickness must have occurred while the patient was covered and the Injury or Sickness must have been covered under the Plan. The patient has been admitted to a Hospital and the attending Physician feels the condition is stabilized. The patient must continue to require an acute level of care, but that care need not be in a Hospital. Note: Case Management is a voluntary service. There are no reductions of benefits or penalties if the patient and family choose not to participate. Condition Management Program The Condition Management Program is a voluntary program designed to help you manage a chronic condition successfully with Outpatient Care and avoid unnecessary emergency care or Inpatient Care. Conditions that can be managed through this program are: Asthma Chronic Obstructive Pulmonary Disease (COPD) Congestive Heart Failure Coronary Artery Disease (CAD) Diabetes Musculoskeletal/low back pain Maternity Metabolic Syndrome Weight Management 42

46 Please note the list of conditions available in the Condition Management Program may change from time to time. If you would like more information, call BCBSIL at (800) BCBSIL representatives are available 24 hours a day, 7 days a week to answer your health-related questions. Covered individuals who have one or more of the chronic conditions that are addressed through the Condition Management Program and who participate in the program to manage their condition may be eligible for a one-time $250 incentive (not available to Benefits-Eligible Crew). The incentive earned during the year will be deposited in your Healthcare Spending Account in the following year. The maximum incentive amount that can be deposited in your Healthcare Spending Account in any given year is $500 per family. Once you or a covered family member has received the $250 incentive, you or that family member will not receive an incentive for any future Condition Management Program participation. The Condition Management Incentive is not available to COBRA and LTD participants. 24/7 Nurseline These nurses are available 24 hours a day, 7 days a week to answer your health-related questions. Call (800) and ask for the 24/7 Nurseline. Special Beginnings - Prenatal Care This team of maternity nurses specializes in providing you or your covered pregnant family member with support and education to help you better understand and manage your pregnancy. Visit or call (800) and ask for Special Beginnings. Lifestyle Management These health coaches specialize in helping you build healthy habits. The services include a smoking cessation program and counseling on topics like managing your weight or blood pressure. Call (800) and ask for Lifestyle Management. Online Tools and Information The BCBSIL website includes access to tools and information to help you manage your health care whether you want to improve your overall health, manage a chronic condition or prepare for a specific medical treatment. Go there to take a Health Assessment, track your personal health record, access online medical libraries and personalized tools, interact with a health coach, sign up for wellness s and more. Log on to Blue Access for Members at Discounts on Health Care Products and Services Discounts negotiated by BCBSIL give you the opportunity to save on a variety of health care products and services. Go to log on to Blue Access for Members, click on the My Coverage Tab and look for Blue365 under Member Advantages/Discounts. 43

47 PRECERTIFICATION FOR HOSPITAL STAYS You must call (800) to precertify all Hospital stays for you or a Dependent to avoid a $250 non-notification penalty. The certification consists of: Certification that a Hospital admission is Medically Necessary. Concurrent review, based on the admitting diagnosis, of the number of days in your Hospital stay requested by the attending Physician. Certification of the length of Hospital stay and discharge planning. This certification is not designed to be the practice of medicine or to be a substitute for the medical judgment of the attending Physician or other healthcare Provider. How It Works You must notify BCBSIL of the scheduled admission date before the start of all non-emergency Hospital confinements for you or a Dependent to avoid paying a $250 non-notification penalty. This penalty does not apply to the Deductible or Out-of- Pocket Maximum. If you do not notify BCBSIL, you will be responsible for the non-notification penalty. In the case of an Emergency Hospital admission, you (or a family member or the Physician) must notify BCBSIL within two working days of the date the confinement begins or pay the $250 non-notification penalty. A working day is a business day and does not include Saturday, Sunday or a state or federal holiday. BCBSIL will send a letter to you confirming you called BCBSIL. A copy is sent to your Physician and the Hospital. If your Hospital admission is for childbirth, you must notify BCBSIL if your Hospital stay extends beyond 48 hours (96 hours for a cesarean section) or the non-notification penalty will be imposed. All decisions concerning your healthcare are the responsibility of you and your Physician. If you have notified BCBSIL as required, your benefits will not be subject to the non-notification penalty even if you and your Physician fail to follow BCBSIL s recommendation regarding your Hospital stay. 44

48 ORGAN AND TISSUE TRANSPLANT PROVISIONS The Plan provides you and your family with a transplant benefit for Approved Transplant Services that helps you obtain quality care and financially protects you from significant health care expenses. Approved Transplants Services can be provided at the Blue Distinction Centers for Transplants (BDCs), at BCBSIL PPO facilities that are not BDCs, and at Non-PPO facilities, but the amount of the benefit depends on the facility used. The highest benefit amount is available at a BDC, a lower level of benefit is available at a BCBSIL PPO that is not a BDC and the lowest level of benefit is available at a Non-PPO facility. The BDCs, are a coordinated set of transplant services provided through a special network of transplant facilities. They are designed to help you obtain the transplant services that are appropriate for you and eligible for reimbursement under the Plan. The BDC benefits include some expenses not otherwise covered by the Plan The following schedule summarizes Coinsurance amounts paid by the Plan, benefit maximums and additional explanations needed for your transplant benefits. For applicable annual Deductibles and Out-of-Pocket-Maximums, see the Medical Plan Highlights. Benefit Description Approved Transplant Services (after Deductible) Organ/Tissue Procurement and Acquisition (after Deductible) Travel and Lodging (up to $50 per person, per night) Allowance Per Transplant The BDC toll-free number: (800) Blue Distinction Centers for Transplants BCBSIL PPO that is not a BCD Non-PPO Gold Silver Bronze 100% 80% 75% 65% 50% of R&C 100% 100% of expenses for the transplant recipient/donor and his or her individual travel companion (both parents, if patient under age 19) 80% 75% 65% 50% of R&C Not Covered Not Covered If you use non-ppo health care Provider, you will be responsible for the difference between the billed charges and any reduction for the R&C charges in addition to your Coinsurance. Approved Transplant Services Approved Transplant Services are Medically Necessary human organ and tissue transplant services and supplies that are provided at a BDC, a BCBSIL PPO facility that is not a BDC or a Non-PPO facility, which are related to transplantation and approved in writing by the Plan prior to the delivery of any services. The BDCs only provide the following Approved Transplant Services: Heart Allogenic/autologous Bone Marrow/stem cell * Kidney/Pancreas Heart/Lung Liver Pancreas Lung *For certain diagnosis See Limitations and Exclusions. Note: Not every BDC is approved for every type of transplant. To find out if a facility is a BCD and is approved for a particular transplant, you must contact BCBSIL. Again, if you need a transplant that is not on the above list, it may 45

49 still qualify as an Approved Transplant Service, but it will be provided through either a BCBSIL PPO that is not a BDC or at a Non-PPO facility. Approved Transplant Services are those incurred for: Pre-transplant evaluation. Organ acquisition/procurement subject to the limitation indicated above. Transplant procedures and associated hospitalization. Transplant-related follow-up care provided by the designated transplant facility for up to 1 year. Pharmacy supplies and services provided by a BDC facility for immunosuppressant and other transplant-related medications while hospitalized. Donor expenses described above. Transplant-related services provided by a BDC facility that are associated with the transplant events listed above, including laboratory and other diagnostic services. Physician services related to the transplant events listed above. Travel and lodging expenses for the patient/donor and one other individual if the transplant is at a BDC facility. If the patient is a minor, the Plan will consider expenses for two individuals to accompany the patient. Benefits also include travel to and from lodging near a designated transplant facility for the pre-transplant evaluation. Per IRS guidelines, lodging benefits are capped at $50 per person, per night. Retransplantation expenses for one retransplant, for a total of two transplants per Covered Person, per Lifetime while covered under this Plan. Pre-Authorization Requirements for Payment of Plan Benefits You are required to call BCBSIL at (800) as soon as the possibility of a transplant is discussed with your Physician to receive authorization for the transplant procedure. When you call, it will be necessary to provide the program with all information needed to complete the review. This call will also satisfy the prior notification requirements as outlined in the Precertification for Hospitalization section of this SPD. In order to receive the highest level of benefits, you must choose a BDC if that option is available to you for your type of transplant. All transplant benefits, including pretransplant evaluation expenses (even if the transplant does not occur), will be provided by the Plan as outlined in the above chart. Reduced Benefits for Failure to Use a Facility in the Blue Distinction Centers for Transplants When you use a BDC facility, your benefits will be paid at the levels indicated in the above chart for Approved Transplant Expenses, organ donor costs, travel and lodging, helping you and the Plan avoid unnecessary expenses. However, if a transplant procedure is not performed at a BDC facility, the Plan will pay benefits at a lower percentage, as indicated in the chart above and no coverage will be provided for organ donor costs or travel, lodging and meal expenses. Second Opinion Policy If a second opinion is required at any time during the evaluation period, the transplant case manager will be responsible for notifying any potential transplant candidates. If you are denied a transplant procedure by the designated BDC facility, you will be referred by the Plan to a second BDC facility. If both facilities determine, for any reason, that you are an unacceptable candidate for the transplant procedure, no coverage will be provided for future transplant-related services and supplies regardless of a third transplant facility s (whether or not a BDC facility) acceptance. Organ/Tissue Acquisition - Donor Expenses Medical expenses of the donor will be covered ONLY if the recipient is a Covered Person under this Plan and the expenses are not covered elsewhere under this Plan or any other benefit plan covering the donor. If the recipient is not a Covered Person, no benefits are payable for donor medical expenses or recipient medical expenses. Limitations and Exclusions A Covered Person is eligible for coverage under the Plan for up to two transplants per Lifetime. Multiple organ/tissue transplants performed at the same time, such as heart/lung, are considered to be one transplant. Also, no benefits are payable for the following charges: Services, supplies, drugs and aftercare for, or related to, artificial or non-human organ implants or transplants. 46

50 Services that are considered Experimental/Investigational or not Medically Necessary. Expenses for services which are specifically excluded under the Non-Covered Expenses section of this Plan, unless a part of a treatment plan approved through the case management program. Services which exceed the R&C charges for facilities that do not participate in the Blue Distinction Centers for Transplants. Services required meeting the patient selection criteria for the approved transplant procedure including, but not limited to, programs such as chemical dependency, detoxification and rehabilitation services, treatment of nicotine or caffeine addiction, services and related expenses for weight loss programs, nutritional supplements, appetite suppressants and supplies of a similar nature not otherwise covered under the Plan. 47

51 NON-COVERED EXPENSES Unless otherwise stated in the SPD, the following expenses are not covered under the Plan. Non-Covered General Medical Expenses In general, the Plan does not cover the following: Expenses which you are not required to pay. Expenses incurred before you or your Dependent becomes covered. Injury or Sickness caused by war or international armed conflict. Injury for you or your covered Dependent(s) that happens during work at any job for pay or profit. Services provided by a person who is a member of your immediate family, who resides in your home or volunteers not generally charging for services. Treatment which results from an Injury or Sickness that arises out of, or as the result of, employment for wage or profit, regardless of whether such treatment is covered by any Workers Compensation or other similar coverage or if covered, whether or not you receive compensation for such treatment. Your covered Dependent s expenses if the Dependent is entitled to benefits for the same expenses under the Plan as an Employee or former Employee. Services or supplies not recommended and approved by a Physician. Care and treatment for which there would not have been a charge if no coverage had been in force. Care and treatment that is Experimental or Investigational. The part of an expense for care and treatment of any Injury or Sickness that is in excess of the R&C charge. Charges for services (i) received as a result of Injury or Sickness caused by or contributed to by engaging or attempting to engage in an illegal act or occupation or (ii) loss due to self-inflicted injury. However, these exclusions do not apply if the Injury or Sickness results from an act of domestic violence or a medical condition (physical or mental). Treatment in a United States government or agency Hospital, unless the veteran is assessed a fee for medical care due to income level, as determined by the Veterans Administration. (In that case, part or all of the assessed fee may be covered, subject to the other provisions of the Plan, i.e., Medically Necessary, Deductible, etc.) Non-Covered Specific Medical Expenses The following specific medical expenses are not covered under the Plan: Abortions performed when the mother s life is not in danger. Acupuncture and manipulation, unless rendered by a chiropractor, doctor of medicine (M.D.), doctor of osteopathy (D.O.) or licensed acupuncturist. Services by a naprapath are excluded. Applied Behavior Analysis. Automated diagnostic Modalities, (e.g., Isokinetic testing equipment like Cybex, Medex). Breast reduction unless all of the following criteria are met: Evaluation of pain symptoms; diagnostic studies. Conservative therapy tried and documented. Management of weight (the patient stays within 20% of ideal weight for at least 6 months). Therapeutic tissue reduction/ratio must meet minimum requirement based on the patient body surface area. Birth Control services and supplies that are not included in the guidelines for women of the Health Resources and Services Administration. Cervical pillows. Chiropractic Care that is continuing/supportive care and/or maintenance/preventive care is not considered to be Medically Necessary. The following diagnostic tests in relation to Chiropractic Care are not considered Medically Necessary and will not be covered: Silhouettogram/metrecom skeletal analysis system, computerized digital surface myography, neurocalometer/neurodermo-thermograph, thermography, gait analysis, contour studies, compustress, H-ware electronic waveform, interro, contact reflex analysis, iridology, spinoscopy, spine or shoulder manipulation under anesthesia; orthomolecular therapy; and digitization. Massage therapy as a Modality is not covered. Continuous passive motion devices used for rehabilitation not in conjunction with total knee replacement or ACL repair. 48

52 Cosmetic surgery, plastic surgery, reconstructive surgery or other services or supplies, that improve, alter or enhance appearance, unless such services are Medically Necessary to restore body function impaired or absent due to a congenital defect, accidental Injury or Sickness. Custodial Care. Dental care and treatment of the teeth and gums, including implants (which are covered under the Dental Plan). This exclusion does not apply to Medically Necessary oral surgery. Diet or weight reduction plans, except if needed to treat a diagnosed illness or disease as specified in Covered Expenses. Food is not a covered expense. Educational services for learning disabilities provided by education Psychologists, speech therapists, audiologists, Social Workers, teachers or schools, except as specified in Covered Expenses. Education, training, and bed and board while confined in an institution that is mainly a school or other institution for training, a place of rest, a place for the aged or a nursing home. EMG (Non-invasive). Eye glasses and contacts, unless required by accidental Injury. Eye surgery to correct refraction errors of the eye, including any confinement, treatment, services, or supplies given in connection with or related to the surgery when the surgery is elective. Foot treatment for: Treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions except open cutting operations or as specified under Medical Supplies in the Covered Expenses section; and Treatment of corns, calluses or toenails unless needed in treatment of a metabolic or peripheral vascular disease. Glucose Monitors. BCBSIL offers glucose meters free of charge to members with diabetes. Call BCBSIL at (800) Glucose Monitors may also be provided through CVS Caremark. Call the CVS Caremark Diabetic Meter Team at (800) to see if you qualify. Hair care and treatment for hair loss including wigs (unless undergoing treatment for cancer). Health club memberships. Hot tubs and Jacuzzis. Impregnation testing, treatment or procedures. This includes: Insemination, in vitro or any other service (i.e., medication, ultrasound, lab services) in conjunction with the procedure being performed. Inducting ovulation for the sole purpose of creating a Pregnancy. Any lab service, medication or treatment associated with or leading up to impregnation is not covered. Infertility treatment and infertility medication, except for medical therapies not related to the treatment of infertility conditions. Laser assisted uvulopalatopharyngoplasty (LAUP). Mandibular repositioning appliance (orthotic) unless due to accidental Injury. May be covered under Dental Plan. Massage therapy. Mental Health and Substance Abuse services not approved as Medically Necessary by GuidanceResources, even when using a network or non-network Provider. Morbid obesity treatment that consists of services of a dietician (unless billed by a Hospital or Physician), spas, weight reduction classes/clubs, exercise equipment, summer camps, diet/fitness programs for weight control, unless specified in Covered Expenses. Certain expenses for treatment of Morbid Obesity are covered, as shown in the Medical Benefits section under Morbid Obesity. See also the diet or weight reduction plan exclusion above. Muscle stimulators. Nutritional supplements that are used to supplement regular meals and are not the only form of nutrition. See Nutritional Supplements in the Covered Services section. Personal comfort items or other equipment, such as, but not limited to, air conditioners, air purification units, orthopedic mattresses, blood pressure instruments, elastic bandages or stockings, nonprescription drugs and medicines, first aid supplies and non-hospital adjustable beds. Personal trainers. Psychiatric or psychological examinations, testing or treatments for purposes of school evaluations, marriage, adoption, medical research, obtaining or maintaining employment, a license, insurance or other official documents, or solely relating to judicial or other administrative proceedings. Radial Keratotomy or any correction of refractive error by any method, including but not limited to Lasik, etc. Replacement of braces of the leg, arm, back, neck or artificial arm or legs, unless there is sufficient change in the individual s physical condition to make the original device no longer functional. Routine blood and urine tests, unless covered under the Preventive Care benefit. 49

53 Routine office visits, medical/physical exams or tests not needed to treat accidental Injury, Sickness or Pregnancy (even if required for school admission or sports participation), except as specifically provided in the Preventive Care benefit. Sclerotherapy in the treatment of varicose veins, when venuous reflux is shown through ultrasound or other scanning study, or in any other circumstance where BCBSIL determines that the treatment is not Medically Necessary. Smoking cessation classes (other than the BCBSIL smoking cessation program) and certain products. See also the exclusion for drugs for tobacco dependency under Non-Covered Prescription Drugs below. Social Workers services, including a psychological or psychiatric Social Worker, except as covered by Hospice or covered as a Mental Health and Substance Abuse benefit. Speech therapy for adults for the following conditions: attention deficit/hyperactivity disorder, bronchitis, laryngitis, conceptual handicaps, myelomengocele, myofunction or tongue thrust therapy, paraplegia, quadriplegia, psycho social speech delay, behavior problems, Spina Bifida, vocal cord nodule, educational or occupational problems. Sterilizations that are not included in the guidelines for women of the Health Resources and Services Administration and vasectomies. Surgical procedures to correct snoring, unless diagnosed with sleep apnea. Surgical procedures due to weight loss in excess of one procedure per Lifetime. TMJ (Temporomandibular Joint) syndrome treatment, including all diagnostic and treatment services and oral surgery related to the treatment of jaw joint problems and TMJ unless directly related to an accidental Injury. There is a TMJ benefit under the Dental Plan. Transexual surgeries. Vision therapy for constant esotropia or constant exotropia. Non-Covered Prescription Drugs The following Prescription Drugs are not covered under the Plan and CVS Caremark: Anti-wrinkle agents (e.g., Renova). Cosmetic drugs, even if ordered for non-cosmetic purposes. Drugs for tobacco dependency beyond 2 courses of treatment annually, and all brand name prescription drugs that have a generic alternative. Drugs payable under any other benefit of the Plan. Experimental and/or Investigational drugs, except when determined on a case-by-case basis, depending on the patient s history, availability of alternative treatments, and results of clinical trials. This exclusion extends, but is not limited to, drugs that have a warning label that says Caution Limited by Federal Law to Investigational Use. (See Experimental and/or Investigational in the Glossary.) Infertility medications. Minoxidil (Rogaine) for alopecia. Non-legend drugs other than those listed. Certain drugs that are not covered on CVS Caremark s formulary and certain over-the-counter drugs or over-the-counter vitamins, even if ordered by a Physician. Drugs over the quantity limit set by CVS Caremark on certain drug classes based on clinical guidelines designed to ensure appropriate usage of those drugs. See How to Use Your Prescription Drug Plan. Prescription Drugs that are not prescribed through a Hospital or Physician s office. Prescriptions you are entitled to at no charge under Workers Compensation laws. Any refill that is more than one year after the latest prescription was written. In addition, the following Prescription Drugs and expenses are not covered by CVS Caremark: Charges for giving or injecting drugs. Drugs given while in a Physician s office or while confined in a Hospital, nursing home or similar place that has its own drug dispensary. However, these drugs may be covered under the Medical Plan. Generic/price difference The difference in price between a Brand Name Drug and a Generic Drug when a Generic Drug is available. Growth hormones, unless approved as Medically Necessary. See Growth Hormones under the Covered Expenses section. Immunization agents, biological sera, blood and blood plasma. Therapeutic devices or appliances, including support garments and other non-medical substances regardless of intended use. 50

54 Drugs taken at the same time and place where the prescription is ordered. See the Medical Benefits section for a complete list of Covered Expenses. 51

55 CONTINUATION OF COVERAGE WHILE ON LEAVE/DISABILITY This section explains what happens to your Medical/Vision Supplement/Dental Plan coverage when you are on a leave of absence. Depending on your job, these types of leaves of absence may be available to you: Job Full-Time and Part-Time Staff Restaurant General and Department Managers Certified Swing Managers Primary Maintenance Benefits-Eligible Crew Short Term Disability Long Term Disability Unpaid Medical leave Military Leave Jury Duty Personal Leave Family and Medical Leave For information on whether you qualify for a leave of absence or how to apply for one, contact the Service Center. Short Term/Long Term Disability If you are on short term disability, deductions for you and your family s coverage under the Medical/Vision Supplement/Dental Plans will automatically be taken from your short term disability benefit payments. However, if your short term disability benefits expire prior to returning to work and you qualify for unpaid medical leave, you may continue your coverage as follows. If you are on long term disability, you may elect to continue coverage under the Medical/Vision Supplement/Dental Plans at the employee rate on an after-tax basis for the period of long term disability, up to a total of 30 months from the date of disability. This includes your six months while on short term disability and up to an additional 24 months of coverage while on long term disability. This continuation of your health insurance benefits is instead of COBRA. When your insurance ends after your additional months of coverage while on long term disability, you will not be eligible for COBRA at that time if your period of time on short and long term disability leave exceeds any COBRA to which you would have been entitled. (See also the Continuation of Coverage under COBRA section.) If you elect to continue your Medical/Vision Supplement/Dental coverage while on long term disability, you will be required to pay the employee portion of the premium (which includes surcharges) on an after-tax basis, in advance, prior to the beginning of the long term disability period, or on a monthly basis by check. If you choose monthly payments, the due date is the first day of each month. If payments are not received within 30 days after the long term disability begins or within 30 days of the due date for the monthly payment, your coverage will terminate as of the end of the month for which your last premium was paid. You will not have the option of allowing Medical/Vision Supplement/Dental coverage to lapse and then picking it up later. Again, once you stop paying the premium, you will no longer have coverage and you will not be entitled to reinstate coverage or qualify for COBRA coverage. If you stop paying premiums and you come back to work in a benefits-eligible position after your long term disability ends, you may make a new election for coverage at that time. The election must be made within 60 days from the date you return to work. 52

56 Unpaid Medical Leave If you go on an approved unpaid medical leave, you may elect to continue coverage under the Medical/Vision Supplement/Dental Plans on an after-tax basis for the period of the leave, up to 30 months from the date of disability. This includes time spent on short term disability. This continuation of your health insurance benefits is instead of COBRA. When your insurance ends after your additional months of coverage while on unpaid medical leave, you will not be eligible for COBRA at that time if your period of time on unpaid medical and short term disability leave exceeds any COBRA to which you would have been entitled. (See also the Continuation of Coverage under COBRA section.) If you elect to continue your Medical/Vision Supplement/Dental coverage while on unpaid medical leave, you will be required to pay the employee portion of the premium (including surcharges) on an after-tax basis, in advance, prior to the beginning of the unpaid medical leave, or on a monthly basis by check. If you choose monthly payments, the due date is the first day of each month. If payments are not received within 30 days after the unpaid medical leave begins or within 30 days of the due date for the monthly payment, your coverage will terminate as of the end of the month for which your last premium was paid. You will not have the option of allowing Medical/Vision Supplement/Dental coverage to lapse and then picking it up later. Again, once you stop paying the premium, you will no longer have coverage and you will not be entitled to reinstate coverage or qualify for COBRA coverage while on unpaid medical leave. If you do not elect to continue coverage during your unpaid medical leave or your coverage terminates due to failure to make a payment and you return to work at McDonald s in a benefits-eligible position, you may elect to continue your coverage under the Medical/Vision Supplement/Dental Plans. If you were on unpaid medical leave and return to work in 30 days or less, your prior election will be reinstated. If you return after a leave of 31 days or more, you may make a new election for coverage. The election must be made within 60 days from the date you return to work. If you do not continue your coverage during unpaid medical leave and your employment with McDonald s terminates, you will not be eligible to continue your coverage through COBRA. Personal, Military, Jury Duty or Other Leave If you are on personal, military leave, jury duty leave (or a leave of absence that has not been approved) of 31 days or more: Your coverage ends as of the end of the month for which your last premium was paid. In that case, you may elect COBRA coverage to be effective as of the first day of the month after your coverage ceases. If you return to work in a benefits-eligible position, you may make a new election for coverage. Your election must be made within 60 days from the date you return to work. If you return to work in a benefits-eligible position in less than 31 days: Your coverage ends as of the end of the month for which your last premium was paid. If your return is in the same Calendar Year, your prior election for coverage is reinstated when you return to work. If your return is in a new Calendar Year, you may make a new election for coverage. Your election must be made within 60 days from the date you return to work. For returns from military leave to a benefits-eligible position, coverage will be effective the first of the month after you return to work, unless you elect to have coverage begin the first of the month in which you return to work (on an after-tax basis for the first month of coverage.) For returns from personal, jury duty or other leaves of absence to a benefits-eligible position, coverage will begin on the first of the month after your return. Family and Medical Leave The Family and Medical Leave Act of 1993 (FMLA) requires employers to provide up to 12 weeks of unpaid, job-protected leave during any 12-month period for certain family and medical reasons to Employees who have been employed with McDonald s for at least 12 months and worked at least 1,250 Hours of Service in the past 12 months. This provision is intended to comply with the law and any pertinent regulations and its interpretation is governed by them. Continuation of Medical/Vision Supplement/Dental and Healthcare Spending Account Coverage. For the duration of the FMLA leave, McDonald s must allow you to maintain your coverage under the Medical/Vision Supplement/Dental Plans and 53

57 Healthcare Spending Account, as applicable. You may continue coverage under these Plans for you and your Dependents on the same terms as if you had continued to work. You must pay the same contributions toward the cost of the coverage that you made while working. The use of an FMLA leave cannot result in the loss of any employment benefit that accrued prior to the start of your FMLA leave. You will be required to pay the employee portion of the premium (including surcharges), on an after-tax basis, in advance, prior to the beginning of the leave or on a monthly basis by check. If you fail to make a payment within 30 days after the FMLA leave begins or within 30 days of its due date, coverage will cease as of the end of the month for which your last premium was paid. Re-enrollment after an FMLA Leave. If any or all of your Medical/Vision Supplement/Dental Plans and Healthcare Spending Account coverage stops while you are on FMLA leave, such coverage will be reinstated on the later of the date you return to work from the FMLA leave or the date you submit your re-enrollment form. If you return to work from FMLA leave in a benefits-eligible position, you may make a new election for coverage. You must re-enroll within 60 days from the date you return to work. In that case, any waiting period will not be applied. The reinstated coverage consists of the benefits in effect prior to your leave and any new or increased benefits added to the Medical/Vision Supplement/Dental Plans or Healthcare Spending Account while you are on FMLA leave. If you do not re-enroll within 60 days from the date you return to work or you do not return to work immediately following the end of the FMLA leave, you cannot enter the Medical/Vision Supplement/ Dental Plans or Healthcare Spending Account until the next annual enrollment period unless you qualify to enroll under a Special Enrollment Period or you have a life event change. However, if your FMLA leave ends and you continue on an approved unpaid medical or personal leave, the rules described above under Unpaid Medical Leave and Personal, Military, Jury Duty or Other Leave apply. 54

58 WHEN MEDICAL, DENTAL AND VISION SUPPLEMENT COVERAGE ENDS When you stop being an active Employee, or your Dependent loses Dependent coverage, contact the McDonald s Service Center to see what options you may have to continue coverage. See the Continuation of Coverage under COBRA section. Your Coverage Your coverage will stop on the earliest of the following: The last day of the month in which your employment ends or you stop being an eligible Employee. The last day of the month for which your last premium was paid. When the Plan stops. Last day of the month in which you no longer meet the eligibility requirements for this coverage. The Plan is amended so that coverage will end for an entire group of Employees and you are in that group. Your Dependent(s) Coverage Coverage for all of your Dependents stops when your coverage stops. If one of the following events occurs, coverage for an individual Dependent will stop sooner, as of the last day of the month in which the event occurs: The Dependent becomes covered as an Employee under this Plan. The Dependent stops being an eligible Dependent. The Plan is amended so that benefits no longer are extended to Dependents. Notwithstanding the above, the Plan Administrator may conduct Dependent audits from time to time to make sure the Dependent criterion is met. You must respond to any audit request and, if requested, provide proof of Dependent status. If you do not respond to a Dependent audit, the Plan Administrator has the discretion to terminate your Dependent coverage, even if your Dependents meet eligibility requirements. If the Plan Administrator discovers, through an audit or other means, that you have enrolled individuals who are not your Dependents for coverage under the Plan, coverage of those individuals will terminate prospectively as soon as administratively possible. The Plan Administrator has discretion to terminate Dependent coverage retroactively and to collect for overpayment if you do not pay premiums for such coverage or if the Plan Administrator finds that you intentionally and fraudulently enrolled individuals who are not your Dependents. If the Plan Administrator finds that you fraudulently covered Dependents, your coverage may be terminated as well. That discretion will be exercised in a nondiscriminatory manner. Handicapped Children A mentally or physically handicapped child s healthcare coverage will not stop due to age. It will continue as long as your Dependent child s coverage continues and the child continues to meet the following conditions: The child is handicapped. The child is not capable of self-support. The child depends mainly on you for support. You must give proof that the child meets these conditions when requested. Proof will not be asked for more than once a year. However, you may not add coverage for a handicapped child who has stopped being an eligible Dependent. 55

59 CONTINUATION OF COVERAGE UNDER COBRA Introduction This section applies to the McDonald's Corporation Health Plan (the Plan ), the Employee Resource Connection and the McDonald's Corporation Healthcare Spending Account Plan. This section primarily contains important information about your right to COBRA coverage under the Plan, which is a temporary extension of coverage under the Plan. This section generally explains COBRA coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. At the end of this section is a description of the COBRA coverage available under the Employee Resource Connection and the Healthcare Spending Account Plan. The right to COBRA coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. For additional information about your rights and obligations under the Plan and under federal law, you should contact the McDonald s Service Center. What Is COBRA Coverage? COBRA coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a "qualifying event." Specific qualifying events are listed later in this section. After a qualifying event, COBRA coverage must be offered to each person who is a "qualified beneficiary." You, your Spouse or Domestic Partner and your Dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. For purposes of COBRA coverage (other than Healthcare Spending Account COBRA), a Domestic Partner of a covered Employee will be treated the same as a Spouse. Under the Plan, qualified beneficiaries who elect COBRA coverage must pay for COBRA coverage. Your cost will generally be the Employee cost of the Medical, Dental and Vision Supplement Plans, as applicable, plus McDonald s cost and a 2% charge for administration. Additional cost may be added if your COBRA coverage extends to 29 months due to disability. If you are an Employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens: Your hours of employment are reduced. Your employment ends for any reason other than your gross misconduct. If you are the Spouse or Domestic Partner of an Employee, you will become a qualified beneficiary if you lose your coverage under the Plan because any of the following qualifying events happens: Your Spouse or Domestic Partner dies; Your Spouse's or Domestic Partner s hours of employment are reduced; Your Spouse's or Domestic Partner s employment ends for any reason other than his or her gross misconduct; Your Spouse or Domestic Partner becomes entitled to Medicare (under Part A, Part B, or both); You become divorced or, under certain circumstances, legally separated from your Spouse; or Your Domestic Partnership terminates. Entitled to Medicare means the individual becomes enrolled in Part A or Part B of Medicare, or both. Your Dependent children will become qualified beneficiaries if they lose coverage under the Plan because any of the following qualifying events happens: The parent-employee dies; The parent-employee's hours of employment are reduced; 56

60 The parent-employee's employment ends for any reason other than his or her gross misconduct; The parent-employee becomes entitled to Medicare (Part A, Part B, or both); The parents become divorced or, under certain circumstances, legally separated or their Domestic Partnership terminates; or The child stops being eligible for coverage under the Plan as a Dependent. When Is COBRA Coverage Available? The Plan will offer COBRA coverage to qualified beneficiaries only after the McDonald s Service Center has been notified that a qualifying event has occurred. McDonald s must notify the McDonald s Service Center of the following qualifying events: The end of employment or reduction of hours of employment; Death of the employee; or The employee becoming entitled to Medicare benefits (under Part A, Part B or both). You Must Give Notice of Some Qualifying Events For the other qualifying events (divorce or, under certain circumstances, legal separation of the Employee and Spouse, termination of a Domestic Partnership or a Dependent child's losing eligibility for coverage as a Dependent), you must notify the McDonald s Service Center within 60 days after the qualifying event occurs. You must provide this notice to the McDonald s Service Center. If you provide this notice to an employee or department of McDonald s other than the McDonald s Service Center, it will not count as notice for purposes of COBRA. The McDonald s Service Center may require you to provide this notice in writing, or to provide documentation supporting your qualifying event. The McDonald s Service Center will send the appropriate election forms to the qualified beneficiary within 14 days after receiving this notice. If you don t receive a form, please contact the McDonald s Service Center. You should note that once your Dependent child reaches age 26, his or her coverage will automatically terminate as of the last day of the month in which he or she attained age 26. Remember, you must notify the McDonald s Service Center within 60 days after your child no longer qualifies as a Dependent child (is age 26). Also, simply providing your Dependent child s age during annual enrollment is not considered notice to the McDonald s Service Center. You must call or write to the McDonald s Service Center informing them that your child no longer qualifies as a Dependent. Also, remember that when you have a newborn or newly adopted child while you are covered under COBRA, you must contact BCBSIL or your HMO/DHMO to enroll the child within 60 days after the child is born or adopted. This 60-day period will not apply under the McDonald s Medical Plan options if you already have Employee & Children or Family coverage. If you do not give notice of the qualifying event in the manner described above, you will not be entitled to COBRA coverage. How Is COBRA Coverage Provided? Once the McDonald s Service Center receives notice that a qualifying event has occurred, COBRA coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA coverage. Covered Employees may elect COBRA coverage on behalf of their Spouses or Domestic Partners, and parents may elect COBRA coverage on behalf of their children. COBRA coverage is a temporary continuation of coverage. When the qualifying event is the death of the Employee, the Employee's becoming entitled to Medicare (under Part A, Part B, or both), your divorce or, under certain circumstances, legal separation, termination of a Domestic Partnership or a Dependent child's losing eligibility as a Dependent, COBRA coverage lasts for up to a total of 36 months. When the qualifying event is termination of employment due to military leave under the Uniformed Services Employment and Reemployment Act of 1994, COBRA coverage lasts for up to a total of 24 months. If the Employee becomes entitled to Medicare before termination of employment, the continuation period for the Employee will be 18 months from the Employee s termination of employment. When the qualifying event is the end of employment or reduction of the Employee's hours of employment, and the Employee became entitled to Medicare less than 18 months before 57

61 the qualifying event, COBRA coverage for qualified beneficiaries other than the Employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered Employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA coverage for his Spouse or Domestic Partner and Dependent children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Entitled to Medicare means that you are enrolled in Part A or B or both of Medicare. Otherwise, in general, when the qualifying event is the end of employment or reduction of the Employee's hours of employment, COBRA coverage generally lasts for only up to a total of 18 months. There are two other ways in which this 18-month period of COBRA coverage can be extended: Disability extension of 18-month period of COBRA coverage If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the McDonald s Service Center within the time described below, you and your entire covered family members may be entitled to receive up to an additional 11 months of COBRA coverage, for a total maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA coverage and must last at least until the end of the 18-month period of COBRA coverage. You must notify the McDonald s Service Center of your disability within 60 days of the latest of: The date of the Social Security Administration determination; The date of your qualifying event; or The date you lose coverage. The McDonald s Service Center may require you to give your notice in writing or to provide additional documentation of your disability. Second qualifying event extension of 18-month period of COBRA coverage If your family experiences another qualifying event while receiving 18 or 24 months of COBRA coverage, your Spouse or Domestic Partner and Dependent children can get up to 18 or 12 additional months of COBRA coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the Plan. This extension may be available to the Spouse or Domestic Partner and any Dependent children receiving continuation coverage if the Employee or former Employee dies, becomes entitled to Medicare (under Part A, Part B, or both), gets divorced or under certain circumstances legally separated or their Domestic Partnership terminates, or if the Dependent child stops being eligible under the Plan as a Dependent, but only if the event would have caused the Spouse, Domestic Partner or Dependent child to lose coverage under the Plan had the first qualifying event not occurred. When Can COBRA Coverage End Early? COBRA coverage can end early on the following dates: The date that McDonald s ceases to provide a group health (medical, vision supplement or dental) or employee assistance program to any Employee; The first day of the month for which you fail to pay your premium for continuation coverage; or The date that the qualified beneficiary first becomes: Covered under any other group health plan, as an employee or otherwise. Entitled to benefits under Medicare after electing COBRA coverage (unless the qualified beneficiary is on COBRA due to USERRA military leave.) Certificate of Creditable Coverage/COBRA If your coverage terminates, in accordance with the requirements of HIPAA, the Plan will provide you with a Certificate of Creditable Coverage notifying you of your creditable coverage under the Plan, including any applicable waiting period or period of COBRA coverage. Such Certificate of Creditable Coverage shall be provided to you at the same time as the notice for electing COBRA coverage is provided. If you are not entitled to COBRA coverage, the Certificate of Creditable Coverage shall be provided within a reasonable time after coverage ceases. A Certificate of Creditable Coverage will also be provided within a reasonable time after COBRA coverage ceases and within a reasonable time after a request for a Certificate of Creditable Coverage is made, provided such request is made within 24 months after your coverage is terminated under the Plan. 58

62 Premium Payments under COBRA Your cost will generally be the Employee cost of the Medical, Dental and Vision Supplement Plans, as applicable, plus McDonald s cost and a 2% charge for administration. Additional cost may be added if your COBRA coverage extends to 29 months due to disability. A qualified beneficiary will have 45 days from the date of his or her election of COBRA coverage to make the first required payment for coverage. You will not be covered under COBRA until you make the required payment. The first payment must include payment for continued coverage from the date coverage stopped because of the qualifying event. After that, premiums are due by the 30 th day of the month for that month s coverage. If your premium is not received by the 30 th day of the month, your COBRA coverage will be terminated effective as of the first day of that month. (No premiums are required for Employee Resource Connection coverage.) If your qualifying event is due to a USERRA military leave, retirement under the Rule of 68, or your severance under the McDonald s Corporation Severance Plan, you are eligible for subsidized COBRA. In that case, your COBRA premium will be equal to the Employee cost of your Medical and Dental coverage and the full COBRA cost for your Vision Supplement coverage, as applicable, for a number of months, as follows: Qualifying Event USERRA Military Leave Retirement under the Rule of 68 Severance Plan Period of Subsidized COBRA Up to 12 months Up to 18 months Your Severance Period under the terms of the Severance Plan After your period of subsidized COBRA ends, you will pay the regular COBRA premium (Employee cost plus McDonald s cost plus 2% administrative fee) for the remainder of your COBRA coverage. Healthcare Spending Account COBRA Coverage If you are participating in the Healthcare Spending Account Plan and experience a qualifying event for COBRA coverage, you are eligible to elect Healthcare Spending Account COBRA coverage. If you elect Healthcare Spending Account COBRA coverage, you may continue to make contributions pursuant to your election until the end of the Calendar Year in which you become eligible for COBRA coverage. Contributions may be continued in the same amount as you were contributing prior to the termination or becoming ineligible. COBRA Healthcare Spending Account contributions are made on an after-tax basis. Employee Resource Connection COBRA Coverage If you are covered under the Employee Resource Connection and you, your covered Spouse or Domestic Partner or your Dependent child experiences a qualifying event, COBRA coverage under the Employee Resource Connection is provided automatically and free of charge for the affected individuals for the applicable period described above in How Is COBRA Coverage Provided? You May Have Other Group Health Coverage Options in Addition to COBRA Coverage Available to You Instead of enrolling in COBRA coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace ( Marketplace ), Medicaid, or other group health plan coverage options (such as a spouse s plan) through what is called a special enrollment period. For example, you may be eligible to buy an individual plan through the Marketplace that costs less than COBRA coverage. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day Special Enrollment period for another group health plan for which you are eligible (such as a spouse s plan), even if that plan generally doesn t accept late enrollees. 59

63 If You Have Questions Questions concerning your Plan or your COBRA coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor s Employee Benefits Security Administration (EBSA) in your area or visit (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA s website.) For more information about the Marketplace, visit Keep Your Plan Informed of Address Changes To protect your family s rights, let the McDonald s Service Center know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to McDonald s Service Center. Plan Contact Information McDonald s Service Center 2111 McDonald s Drive, Dept Oak Brook, IL (877) If you need to obtain a Certificate of Creditable Coverage for your period of COBRA coverage, you should contact BCBSIL at (800)

64 COORDINATION OF BENEFITS If You Have Other Medical/Dental Care Coverage Coordination of benefits sets out rules for the order of payment of covered charges when two or more plans including Medicare are paying. When a person is covered by the Medical and/or Dental Plan and another plan, or the Covered Person s Spouse or Domestic Partner is covered by the Medical and/or Dental Plan and another plan, or the couple s children are covered under two or more plans, the plans will coordinate benefits when a claim is received. How Coordination of Benefits Works When a person is covered under more than one medical or dental care plan, the plan that has the first obligation to pay is called the primary plan, while the other plan is called the secondary plan. This provision does not apply to CVS Caremark. If the Medical and/or Dental Plan is considered primary, it will pay benefits first. Benefits under the Medical and/or Dental Plan will not be reduced due to benefits payable under other plans. Other plans include no fault automobile insurance and government or tax support programs except Medicare. If the Medical and/or Dental Plan is considered secondary, benefits under the Medical and/or Dental Plan (including your HRA) may be reduced due to benefits payable under other plans primary to the Medical and/or Dental Plan. The Medical and Dental Plans have a non-duplication of benefits clause. Non-duplication of benefits means that between both claims administrators, the amount payable will not exceed what the Medical or Dental Plan would pay if BCBSIL were the only claims administrator, or the Medical and/or Dental Plan was the primary plan. Therefore, one should not expect to always get reimbursed for the entire amount of billed charges just because they pay two premiums. Rules for Determining the Primary Plan Certain rules are used to find out which plan is primary and which plan is secondary. The rules are used until one is found that applies to the situation. They are always used in the following order: 1. A plan that has no coordination of benefits provision will be primary to a plan which does have a coordination of benefits provision. 2. A plan which covers a person as an Employee or retiree will be primary to a plan that covers the same person as a dependent. 3. A plan covering the individual as an Employee or retiree (or as that individual s dependent) will be primary to the plan providing continuation coverage under COBRA or state law. 4. A person may be covered as a dependent under two or more plans. The plan of the covered individual whose birthday falls earlier in a Calendar Year is determined to be primary before the plan of the covered individual whose birthday falls later in that same Calendar Year (based on month and day only). If both covered individuals have the same birthday, the plan covering the person for the longest time is primary. If the other benefit plan does not have the rules described immediately above, but instead has a rule based upon the gender of the covered individual, and if, as a result, the plans do not agree on the order of benefits, the rule in the other benefit plan will determine the order of benefits. If a Dependent child is covered under more than one plan, the primary plan is the plan of the parent whose birthday (month and day) is earlier in the Calendar Year if: The parents are married; or The parents are not separated (regardless of whether they ever have been married); or A court decree awards joint custody without specifying that one parent has the responsibility to provide health care coverage. If the specific terms of a court decree state that one of the parents is responsible for the child s health care coverage or expenses and the plan of that parent has knowledge of the decree, that plan is primary. If the parent designated by the decree has no coverage for the child but that parent s Spouse does, the Spouse s plan is primary. 61

65 If the parents are not married, are separated (regardless of whether they were ever married), or are divorced and there is no court decree allocating responsibility for the child s health care coverage or expenses, the order of benefit determination among the plans of the parents and the parents Spouses (if any) is: The plan of the custodial parent; The plan of the Spouse of the custodial parent; The plan of the noncustodial parent; The plan of the Spouse of the noncustodial parent. If none of the above rules apply, the plan that has covered the individual for the longer period of time will be considered primary. You will be asked once a year at annual enrollment time for current coverage information regarding coverage under other plans. New hires will be asked when first enrolling and each year thereafter. Automobile Insurance The Plan provides benefits relating to medical expenses incurred as a result of an automobile accident on a secondary basis only. Benefits payable under the Plan will be coordinated with and secondary to benefits provided or required by any group or individual automobile, homeowner s or premises insurance, including medical payments, personal injury protection, or no-fault coverage, regardless of any provision to the contrary in any other policy of insurance when such insurance is available. If no such insurance is available, the Plan provides such benefits on a primary basis. Any benefits provided by the Plan will be subject to the Plan s reimbursement and/or subrogation provisions. 62

66 MEDICARE When the Medical Plan Pays First You or your Spouse or Domestic Partner may reach age 65 and become entitled to Medicare while you are still covered under the Plan as an active Employee. You, your Spouse or Domestic Partner or your Dependent children may also become entitled to Medicare before attaining age 65 due to disability or end stage renal disease. In general, when you and/or your Spouse or Domestic Partner or children are covered by both the Medical Plan and Medicare, the Medical Plan will pay first before Medicare. Under Medicare rules, you attain age 65 on the day before your 65 th birthday. Entitled to Medicare means that you are enrolled in Part A or B or both of Medicare. However, in certain situations, you and/or your Dependents may be covered by both the Medical Plan and Medicare, but Medicare would pay first, as described below. When Medicare Pays First There are three situations where you may be covered by both the Medical Plan and Medicare but Medicare will pay first. These situations are: Where you are entitled to Medicare due to disability but are not considered an active individual under federal law. Where you are entitled to Medicare due to end stage renal disease, but only after you have been eligible for Medicare benefits due to end stage renal disease for 30 months. Where you are on COBRA coverage and are covered by Medicare. (This is a situation where you became entitled to Medicare before becoming eligible for COBRA coverage. If you become entitled to Medicare after COBRA coverage begins, COBRA coverage ends.) In these situations where Medicare pays first, the Medical Plan pays benefits as described below: If the Provider has agreed to limit charges for services and supplies to the charges allowed by Medicare, the Medical Plan determines the amount of covered expenses based upon the amount of charges allowed by Medicare. If the Provider has not agreed to limit charges for services and supplies to the charges allowed by Medicare, the Medical Plan determines the amount of covered expenses based on the lesser of the following: The R&C charges (if an out-of-network Provider) or the contracted PPO rate (if a network Provider); or The amount allowed by Medicare. The Medical Plan determines the amount payable without regard to Medicare benefits. Then the Medical Plan subtracts the amount payable under Medicare for the same expenses from the Medical Plan benefits. The Medical Plan pays only the difference between Medical Plan benefits and Medicare benefits. If you are also covered under another employer s plan, the same expenses payable secondary to Medicare under the Medical Plan may also be payable under the employer s plan. If the benefits under that other employer s plan must be paid before Medicare because of federal law, the Medical Plan still subtracts the amount of Medicare benefits payable determined as if benefits were not payable under that plan. The Medical Plan will assume you are enrolled in Medicare Part A/B if eligible and will subtract the amount that Medicare would have paid, whether or not you have actually enrolled in Medicare. Medicare and Coordination of Benefits If you are also covered under another employer s plan (other than the Medical Plan) and federal law requires the other group plan to pay primary to Medicare, the Medical Plan is secondary to both that plan and Medicare. This is true even if the Medical Plan is determined to be primary to that other plan. Federal law determines the order of payment between Medicare and the other plan. 63

67 Medicare Enrollment Requirements If you are covered under the Medical Plan when you reach age 65, you may be eligible to enroll for Medicare Parts A and/or B at that time. If you remain covered under the Medical Plan after age 65 and do not enroll in Part B Medicare, under present law you or your Spouse, if he or she is at least age 65, will be entitled to a special Medicare enrollment period at the time your coverage under the Medical Plan terminates. If you do not enroll within the Special Enrollment period, your Part B premiums will be higher when you do enroll and you may have gaps in coverage. 64

68 IMPORTANT NOTICE FROM McDONALD S ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND MEDICARE Please read this notice carefully. This notice has information about your current prescription drug coverage with the McDonald s Plan PPO and HMO options and about your options under Medicare s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare prescription drug plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. McDonald s has determined that the prescription drug coverage offered by the McDonald s Plan PPO and HMO options are, on average for all Plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and are therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join a Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 th to December 7 th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens to Your Current Coverage if You Decide to Join a Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Plan coverage will be affected. You cannot drop your prescription drug coverage under the McDonald s Plan without dropping the rest of your medical coverage. You should note that your current medical coverage pays for other health expenses, in addition to prescription drugs, and you will still be eligible to receive all of your current and prescription drug benefits if you choose to enroll in a Medicare prescription drug plan, although the benefits between the Medicare plan and the McDonald s Plan will be coordinated. In most situations, the McDonald s Plan will pay first before the Medicare plan. If you do decide to join a Medicare drug plan and drop your current McDonald s Plan coverage, including the prescription drug coverage, be aware that you and your Dependents will not be able to get this coverage back later except during annual enrollment or if you have a qualifying life event. When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan? You should also know that if you drop or lose your current coverage with the McDonald s Plan and don t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without Creditable Coverage, your premium may consistently be at least 19% higher than 65

69 the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information about This Notice or Your Current Prescription Drug Coverage Contact the McDonald s Service Center at (877) for further information. NOTE: You ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the McDonald s Plan changes. You also may request a copy of this notice at any time. For More Information about Your Options under Medicare Prescription Drug Coverage More detailed information about Medicare plans that offer prescription drug coverage is in the Medicare & You handbook. You ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the Medicare & You handbook for their telephone number) for personalized help. Call (800) MEDICARE ((800) ). TTY users should call (877) If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at or call them at (800) (TTY (800) ). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). January 1, 2015 McDonald s Corporation Service Center 2111 McDonald s Drive, Dept 0028 Oak Brook, IL Phone: (877)

70 REPAYMENTS TO THE PLAN Reimbursement to the Plan This section applies whenever another party (including your own insurer under an automobile or other policy) is legally responsible or agrees to compensate you or your Dependent, by settlement, verdict or otherwise, for an illness or injury. The compensation includes, but is not limited to, funds from the following sources: insurance coverage under your own or another automobile or other policy, uninsured and underinsured motorist coverage, any no-fault insurance, medical payment coverage (auto, homeowners or otherwise), workers compensation settlement, compromises or awards, other group insurance (including student plans), and direct recoveries from liable parties. This section is not an imposition of personal liability, but reflects the equitable obligation to reimburse the Plan from any recovery by you, your Dependent or representative. If another party is legally responsible or agrees to provide any compensation, you or your Dependent (or legal representatives, estate, heirs or trusts established on behalf of either you or your Dependent), must promptly reimburse the Plan for any benefits it paid relating to that illness or injury, up to the full amount of the compensation received from the other party (regardless of how that compensation may be characterized and regardless of whether you or your Dependent have been made whole). If the Plan does not receive restitution from you or your Dependent as required by this section, the Plan may reduce or deny future benefits (whether or not related to that illness or injury) on the basis of the compensation received or constructively received by you, your Dependent or representative. In order to secure the rights of the Plan under this section, you or your Dependent hereby: Grant to the Plan and BCBSIL on behalf of the Plan a first priority lien against the proceeds of any such settlement, verdict or other amounts received by you or your Dependent or your representative; Assign to the Plan and BCBSIL on behalf of the Plan any benefits you or your Dependent may have under any automobile policy or other coverage, to the extent of the Plan's claim for reimbursement; and Agree that you, your Dependent, or representative will hold any compensation in constructive trust for the benefit of the Plan and all its participants who have contributed to the funding of the Plan. You or your Dependent must cooperate with the Plan, BCBSIL and their agents, and must sign and deliver such documents as the Plan or its agents reasonably request to protect the Plan's right of reimbursement. You or your Dependent must also provide any relevant information, and take such actions as the Plan, BCBSIL or their agents reasonably request to assist the Plan in making a full recovery of the reasonable value of the benefits provided. You or your Dependent must not take any action that prejudices the Plan's right of reimbursement. The Plan may reduce or deny future benefits on the basis that you or your Dependents have refused to sign and deliver such documents as the Plan, BCBSIL or their agents reasonably request to protect the Plan's right of reimbursement. The reimbursement required under this provision will not be reduced to reflect any costs or attorneys' fees incurred in obtaining compensation unless separately agreed to, in writing, by the Plan Administrator, in the exercise of its sole discretion. Any socalled Fund Doctrine, Common Fund Doctrine or Attorney s Fund Doctrine shall not limit, reduce or defeat the recovery rights of the Plan. Subrogation This section applies whenever another party is legally responsible or agrees to compensate you or your Dependent for you or your Dependent's Sickness or Injury and the Plan has paid benefits related to that Sickness or Injury. The compensation includes, but is not limited to, funds from the following sources: insurance coverage under your own or another automobile or other policy, uninsured and underinsured motorist coverage, any no-fault insurance, medical payment coverage (auto, homeowners or otherwise), workers compensation settlement, compromises or awards, other group insurance (including student plans), and direct recoveries from liable parties. This section is not an imposition of personal liability, but reflects the equitable right of the Plan to restore Plan assets to the Plan for the benefit of all participants. The actions of another party caused the Plan to incur expenses it would not normally have incurred, therefore the Plan is entitled to pursue any cause of action or pursue any remedy available to you or your Dependents (regardless of how that action may be characterized and regardless of whether you or your Dependent have been made whole). 67

71 The Plan is subrogated to all of the rights of you or your Dependent against any party liable for you or your Dependent's Sickness or Injury to the extent of the reasonable value of the benefits provided to you or your Dependent under the Plan. The Plan may assert this right independently of you or your Dependent. You or your Dependent are obligated to cooperate with the Plan and its agents in order to protect the Plan's subrogation rights. Cooperation means providing the Plan or its agents with any relevant information requested by them, signing and delivering such documents as the Plan or its agents reasonably request to secure the Plan's subrogation claim, and obtaining the consent of the Plan or its agents before releasing any party from liability for payment of medical expenses. If you or your Dependent enter into litigation or settlement negotiations regarding the obligations of other parties, you or your Dependent must not prejudice, in any way, the subrogation rights of the Plan under this section. Please see the Reimbursement to the Plan section above regarding your or your Dependent s obligations regarding any compensation received or constructively received. The costs of legal representation of the Plan in matters related to subrogation will be borne solely by the Plan. The costs of legal representation of you or your Dependent must be borne solely by you or your Dependent. Any so-called Fund Doctrine, Common Fund Doctrine or Attorney s Fund Doctrine shall not defeat the recovery of rights of the Plan. Recovery of Excess Payments Whenever payments have been made in excess of the amount necessary to satisfy the provisions of this Plan, the Plan has the right to recover these excess payments from any individual (including you), insurance company or other organization to whom the excess payments were made or to withhold payment, if necessary, on future benefits until the overpayment is recovered. If excess payments were made for services rendered to you or your Dependent(s), the Plan has the right to withhold payment on your future benefits and/or the future benefits of your Dependents until the overpayment is recovered. Further, whenever payments have been made based on fraudulent information provided by you, the Plan may exercise all available legal rights, including its right to withhold payment on future benefits, until the overpayment is recovered. 68

72 APPLYING FOR BENEFITS Pre-Determination of Dental Benefits You should obtain a Pre-Determination of Benefits for any Dental treatment to tell you how much the Dental Plan will pay for the particular treatment before receiving the services. To obtain a Pre-Determination of Benefits, simply have your Provider submit the dental estimate to BCBSIL before the treatment or service is given. The Provider should list the services and charges as part of the estimate and send to BCBSIL at: BCBS of Illinois P.O. Box Belleville, IL BCBSIL will tell you and your Provider the amount the Dental Plan will pay. A Pre-Determination of Benefits is not required, but is highly recommended. If you do not obtain a Pre-Determination of Benefits, payment will be based on whatever information BCBSIL has about the case. Eligibility or Enrollment Review If you believe that you have been improperly denied participation or enrollment in the Medical/Dental/Vision Supplement Plan, Employee Resource Connection or Healthcare Spending Account Plan, you can make a request in writing to the Plan Administrator (Welfare Plan Administrative Committee). You must make your request within one year of the date you would have first become a participant in the plan if you were eligible for participation. The Plan Administrator will review your request and render its determination within 90 days after your request is received, unless an extension of time is required by the Plan Administrator. If an extension is necessary, you will receive written notice of the extension within the initial 90-day period. The notice will indicate the reasons for the extension and the date by which the Plan Administrator expects to make its determination. If your initial request is denied, in whole or in part, you may make a written request for reconsideration by the Plan Administrator within 60 days of receipt of the notification of denial. You can submit written issues and comments regarding your request to the Plan Administrator. The Plan Administrator will make a decision on your request for review within 60 days after receipt of your request, unless special circumstances (such as the need to hold a hearing) require an extension of time for processing, in which case it will make its decision as soon as possible. If an extension of time is necessary, you will be provided written notice of the extension before the end of the initial 60-day period. If your request is denied, in whole or in part, the decision will specify the reasons for the denial. Medical/Dental Claims To claim medical or dental benefits under the Medical or Dental Plan, you must give BCBSIL written proof of your expenses within 90 days after the date the expenses are incurred. If it is not possible to give the proof within 90 days, give the proof as soon as possible, but not later than one year after the date expenses are incurred. Expenses submitted after one year from when incurred will not be paid. Your Provider may submit the claim to BCBSIL directly. If your Provider does not submit the claim on your behalf, contact BCBSIL Customer Service at (800) to obtain the proper address for your area to submit the claim. To file a claim, you must obtain a claim form from the BCBSIL website at or you can call BCBSIL Customer Service to have one sent to you. Simply submit the claim form and all complete bills to the applicable BCBSIL address. Make sure to indicate on each bill all required information: Group number shown on your ID card. Employee s Social Security Number or your Identification number from your insurance card and current address. (Please advise the McDonald s Service Center of any changes.) Patient s full name and relationship to the Employee. (Indicate if a handicapped Dependent child.) 69

73 Provider s name, address and tax identification number. Date of service, charges, diagnosis code and procedure information. Prescription Drug Claims In some cases, you will need to file CVS Caremark claims directly with CVS Caremark, as follows: If you do not have your ID card with you when filling a prescription. If your prescription is declined at the Pharmacy when you use your ID card and you wish to file a claim for benefits. If the Pharmacy is not in the CVS Caremark network. For these situations, you need to file a CVS Caremark claim form directly with CVS Caremark. You can get a CVS Caremark claim form online from Claims will be paid directly to you. You cannot assign benefits. Mental Health and Substance Abuse Claims In-network claims are filed directly with ComPsych by the Provider. Out-of-network claims for both Inpatient and Outpatient Care are filed directly with ComPsych by you or your Provider. Send a copy of your claim (with Provider s name, address and tax ID number, date of service, billed amount for each service, diagnosis code and procedure code) to: ComPsych P.O. Box 8379 Chicago, IL Out-of-network Providers may require you to pay for the services at the time they are rendered. Vision Supplement and Healthcare Spending Account Claims Instructions for how to receive benefits for the Vision Supplement Plan are found in the Vision Supplement Plan section and for the Healthcare Spending Account in the Healthcare Spending Account section. Also, the procedures described below in Initial Claim Determinations and How to Appeal a Claim will apply to Healthcare Spending Account claims. Employee Resource Connection It is not necessary to file claims under this Program. Claims are automatically processed by ComPsych. How and When Medical/Dental Plan Claims Are Paid When you incur Covered Expenses, your Provider should submit the claim to BCBSIL for Medical Plan claims or ComPsych for Mental Health and Substance Abuse claims. If the Provider is in-network, payment will be based on the negotiated rate. If the Provider is out-of-network, payment will be based on R&C charges. If an in-network Provider submits your bill, benefits will be paid to the Provider. For out-of-network Providers, all benefits will be paid to you after BCBSIL or ComPsych receives satisfactory proof of service. With respect to Mental Health/Substance Abuse claims, under certain conditions you may assign your benefits to the Provider of care, which means ComPsych will make payments directly to the healthcare Provider. If you assign your Mental Health/Substance Abuse benefits, you will be responsible for the difference between what the Plan pays and the actual charges. If a claim payment/reimbursement check sent to you or your Provider from a Claims Administrator remains uncashed for one year from the date of issue, the Claims Administrator will return the uncashed check amounts to the Plan. You will forfeit those uncashed check amounts within a reasonable time after they are returned to the Plan, and no checks will be reissued to you or your Provider with respect to those claims. Initial Claim Determinations For purposes of the claim determination and appeal procedures, the term Plan refers to the Medical Plan Dental Plan, Vision Supplement Plan (for eligibility issues), Employee Resource Connection and Healthcare Spending Account. Once you have 70

74 filed a claim for benefits as described above, the Plan (using BCBSIL, CVS Caremark or ComPsych as the Claims Administrator, depending on the claim involved) will make an initial claim determination and send you a notice: Within 72 hours after receipt of an Urgent Care Claim, either orally or in writing. If made orally, the notice will also be provided to you in writing within 3 days of any oral communication. Within 15 days after receipt of a Pre-Service Claim, in writing. Within 30 days after receipt of a Post-Service Claim, in writing. These time periods begin upon the Plan s receipt of a claim for benefits filed in accordance with the terms of the Plan specific to that type of claim. If the claim is wholly or partially denied, the notice from the Plan will also contain the following information: The specific reason(s) for the denial and reference to the specific Plan provisions on which the denial is based. If a protocol was followed, then the notice will state that a protocol was relied upon and that a copy of that protocol is available free of charge upon request. If the claim is denied because it does not meet the definition of Medically Necessary or is Experimental/Investigational (or similar exclusion or limit), the notice will also state that an explanation of the scientific or clinical judgment used to make the determination can be provided free of charge upon request. Subject to privacy laws and other restrictions, if any, the identification of the claim, date of service, health care Provider, claim amount (if applicable) and denial codes with their meanings and the standards used. (Diagnosis and treatment codes are available upon request.) A description of any additional information or material needed to complete the claim and an explanation of why such material or information is necessary. A description of the Plan s appeal procedure and the time limits for such procedures, including a statement of your right to bring a civil action under Section 502(a) of ERISA. In certain situations, a statement in a non-english language(s) that future notices of claim denials and certain other benefit information may be available in such non-english language(s). The right to request, free of charge, reasonable access to and copies of all documents, records and other information relevant to the claim for benefits. If the denied claim is an Urgent Care Claim, a description of the expedited review process for such claims. Special Rules for Urgent Care Claims If additional information is needed to make an Urgent Care Claim determination, the Plan will notify you within 24 hours after receipt of the claim and give you a description of any information needed to complete the claim. You then have 48 hours from the receipt of the notice to provide the requested information, if any. The Plan will then make its initial determination no later than 48 hours after either (i) receiving your additional information or (ii) the end of the time period by which you were to provide the additional information. An Urgent Care Claim requesting an extension of a course of treatment must be made at least 24 hours prior to the expiration of the original course of treatment. The Plan will make an initial determination on this extension within 24 hours of the receipt of the request for extension. Extension of Time The Plan may extend the time periods for making its initial determination for Pre-Service and Post-Service Claims, if necessary. The time period for the initial determination can be extended no more than 15 days from the end of the initial period. (There is no extension for Urgent Care Claims). You will be notified before the end of the initial time period of any extension, the length of the extension, the reason for the extension and the date by which the Plan expects to render a decision. If you are notified of an extension, you will have 45 days from the receipt of that notice to respond. 71

75 APPEALS FOR MEDICAL, DENTAL, EMPLOYEE RESOURCE CONNECTION AND HEALTHCARE SPENDING ACCOUNT CLAIMS How to Appeal a Claim Internal Appeal If a Medical, Dental, Healthcare Spending Account or Employee Resource Connection claim is denied, either totally or partially, you will receive an Adverse Benefit Determination from the Claims Administrator as indicated above. You then have a right to file a request for an appeal of the claim denial within 180 days of the denial to the Claims Administrator. In the case of Urgent Care Claims, a request for an expedited appeal may be submitted orally and all necessary information, including the Plan s benefit determination upon review, may be transmitted via telephone, facsimile or other similarly expedient methods. Your Provider may file an appeal on your behalf only if you sign an authorization form from the Claims Administrator for this purpose. Note that the information in this section about Urgent Claims, Pre-Service Claims and external review does not apply to the Healthcare Spending Account. In addition, the external review provisions do not apply to Dental claims. Your request for an internal appeal must be made as follows: The request may be submitted in writing, stating in clear and concise terms the reason(s) for disagreement with the Adverse Benefit Determination. (Requests to BCBSIL may also be submitted orally.) The request must include your name and Social Security number or your ID number on your insurance card as well as the patient s name. You must submit any written comments, documents, records and other information that you have that relate to the claim. You may request, free of charge, reasonable access to documents, records and other information relevant to the disputed claim. The appeal request must be addressed to Claims Administrator at the following address: Medical/Dental Appeals Prescription Drug Appeals Mental Health/Substance Abuse/ Employee Resource Connection Appeals Healthcare Spending Account Appeals: Blue Cross Blue Shield of Illinois Claim Review Section P.O. Box 2401 Chicago, Illinois Caremark Inc. Appeals Department MC109 P.O. Box Phoenix, AZ Fax: (866) ComPsych Appeals Coordinator 455 N. Cityfront Plaza Dr. 13th fl., NBC Tower Chicago, IL PayFlex Systems USA, Inc. Attn: Reimbursement Accounts P.O. Box 3039 Omaha, NE In support of your appeal, you have the option of presenting evidence and testimony to the Claims Administrator, by phone or in person at a location of the Claims Administrator s choice. You may ask to review your file and any relevant documents and may submit written issues, comments and additional medical information within 180 days after you receive notice of an Adverse Benefit Determination or at any time during the appeal process. 72

76 If you do not file a request for review within 180 days of the denial, you will have no further right of review and no right to bring action in any court, and the denial of the claim shall be final and binding. The Internal Appeal Determination by the Claims Administrator The decision upon internal appeal will be made by the applicable Claims Administrator. The internal appeal will not defer to the initial claim determination and will take into account all comments, documents, records and other information submitted on your behalf without regard to whether such information was previously submitted or relied upon in the initial determination. In deciding the internal appeal of any denied claim that is based in whole or in part on a medical judgment, the Claims Administrator shall consult with an appropriately qualified health care professional who was not consulted in connection with the denied claim (or a subordinate of such individual.) Before you may bring any action to recover benefits, you much exhaust the appeal process and must raise all issues with respect to a claim and must file an appeal and the appeal must be finally decided by the Claims Administrator. The Claims Administrator will provide you with a written response: Within 72 hours after receipt of the request for review in the case of Urgent Claims. Within 30 days after receipt of the request for review in the case of Pre-Service Claims. Within 60 days after the receipt of the request for review in the case of Post-Service Claims. If, upon review, the claim is wholly or partially denied, the Adverse Benefit Determination will contain the following information: The specific reason(s) for the denial and reference to the specific Plan provisions on which the denial is based. If a protocol was followed, then the notice will state that a protocol was relied upon and that a copy of that protocol is available free of charge upon request. If the claim is denied because it does not meet the definition of Medically Necessary or is Experimental/Investigational (or similar exclusion or limit), the notice will also state that an explanation of the scientific or clinical judgment used to make the determination can be provided free of charge upon request. Subject to privacy laws and other restrictions, if any, the identification of the claim, date of service, health care Provider, claim amount (if applicable) and denial codes with their meanings and the standards used. (Diagnosis and treatment codes are available upon request.) A description of any additional information or material needed to complete the claim and an explanation of why such material or information is necessary. A description of the Plan s appeal procedure and the time limits for such procedures. In certain situations, a statement in a non-english language(s) that future notices of claim denials and certain other benefit information may be available in such non-english language(s). The right to request, free of charge, reasonable access to and copies of all documents, records and other information relevant to the claim for benefits. If the denied claim is an Urgent Care Claim, a description of the expedited review process for such claims. An explanation of the Claims Administrator's external review processes (and how to initiate an external review) and a statement of your right, if any, to bring a civil action under Section 502(a) of ERISA following a final denial on external appeal. If the Claims Administrator's decision is to continue to deny or partially deny your claim for lack of medical necessity or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Independent External Review You may make a request for a standard external review or expedited external review of certain Adverse Benefit Determinations by an independent review organization (IRO). External review is available for Adverse Benefit Determinations involving Medical, Prescription Drug, Mental Health\Substance Abuse and Employee Assistance Program claims that involve the exercise of medical judgment or the rescission of benefits. Request for external review. Within 4 months after the date of receipt of a notice of an Adverse Benefit Determination from the Claims Administrator, you must file your request for standard external review. 73

77 Preliminary review. Within 5 business days following the date of receipt of the external review request, the Claims Administrator must complete a preliminary review of the request to determine whether: You are, or were, covered under the Plan at the time the health care item or service was requested or, in the case of a retrospective review, was covered under the Plan at the time the health care item or service was provided; The Adverse Benefit Determination does not relate to your failure to meet the requirements for eligibility under the terms of the Plan; You have exhausted the Claims Administrator's internal appeal process, unless you are not required to exhaust the internal appeals process. Please see Exhaustion below for additional information on exhaustion of the internal appeal process; and You have provided all the information and forms required to process an external review. You will be issued a notification in writing within 1 business day after the Claims Administrator completes the preliminary review if your request is eligible or if further information or documents are needed. You will have the remainder of the 4- month appeal period (or 48 hours following receipt of the notice, whichever is later) to perfect the appeal request. If your claim is not eligible for external review, the Claims Administrator will outline the reasons it is ineligible in the notice, and provide contact information for the Department of Labor's Employee Benefits Security Administration - toll-free number (866) 444- EBSA (3272). Referral to Independent Review Organization. When an eligible request for external review is completed within the time period allowed, the Claims Administrator will assign the matter to an independent review organization (IRO). The IRO assigned will be accredited by URAC or by a similar nationally-recognized accrediting organization. Moreover, the Claims Administrator will take action against bias and to ensure independence. The IRO must provide the following: Utilization of legal experts where appropriate to make coverage determinations under the Plan. Timely notification to you in writing, of the request's eligibility and acceptance for external review. This notice will include a statement that you may submit in writing to the assigned IRO within 10 business days following the date of receipt of the notice, and additional information that the IRO must consider when conducting the external review. The IRO is not required to, but may, accept and consider additional information submitted after 10 business days. Within 5 business days after the date of assignment of the IRO, the Claims Administrator must provide to the assigned IRO the documents and any information considered in making the Adverse Benefit Determination. If the Claims Administrator fails to timely provide the documents and information, the assigned IRO may terminate the external review and make a decision to reverse the Adverse Benefit Determination. Within 1 business day after making the decision, the IRO must notify you and the Claims Administrator. Upon receipt of any information that you submitted, the assigned IRO must within 1 business day forward the information to the Claims Administrator. Upon receipt of any such information, the Claims Administrator may reconsider its Adverse Benefit Determination that is the subject of the external review. Reconsideration by the Claims Administrator must not delay the external review. The external review may be terminated as a result of the reconsideration only if the Claims Administrator decides, upon completion of its reconsideration, to reverse its Adverse Benefit Determination and provide coverage or payment. Within 1 business day after making such a decision, the Claims Administrator must provide written notice of its decision to you and the assigned IRO. Review all of the information and documents timely received. In reaching a decision, the assigned IRO will review the claim and not be bound by any decisions or conclusions reached during the Claims Administrator's internal claims and appeals process. In addition to the documents and information provided, the assigned IRO, to the extent the information or documents are available and the IRO considers them appropriate, will consider the following in reaching a decision: Your medical records. The attending health care professional's recommendation. Reports from appropriate health care professionals and other documents submitted by the Claims Administrator, you, or your Provider. The terms of the Plan to ensure that the IRO's decision is not contrary to the terms of the Plan, unless the terms are inconsistent with applicable law. Appropriate practice guidelines. Any applicable clinical review criteria developed and used by the Claims Administrator, unless the criteria are inconsistent with the terms of the Plan or with applicable law. The opinion of the IRO's clinical reviewer or reviewers after considering information described in this notice to the extent the information or documents are available and the clinical reviewer or reviewers consider appropriate. 74

78 Written notice of the final external review decision must be provided within 45 days after the IRO receives the request for the external review. The IRO must deliver the notice of final external review decision to the Claims Administrator and you or your authorized representative. The notice of final external review decision will contain: A general description of the reason for the request for external review, including information sufficient to identify the claim (including the date or dates of service, the health care Provider, the claim amount (if applicable) and the reason for the previous denial. Diagnosis and treatment codes are available upon request.) The date the IRO received the assignment to conduct the external review and the date of the IRO decision. References to the evidence or documentation, including the specific coverage provisions and evidence-based standards, considered in reaching its decision. A discussion of the principal reason or reasons for its decision, including the rationale for its decision and any evidence-based standards that were relied on in making its decision. A statement that the determination is binding except to the extent that other remedies may be available under applicable law to either you or the Claims Administrator. A statement that judicial review may be available. Reversal of the Plan's decision. Upon receipt of a notice of a final external review decision reversing the Adverse Benefit Determination, the Claims Administrator immediately must provide coverage or payment for the claim, although the Plan reserves any rights to a subsequent judicial review. Expedited External Review Request for expedited external review. The Claims Administrator must allow you or your authorized representative to make a request for an expedited external review with the Claims Administrator at the time you receive an Adverse Benefit Determination if: The Adverse Benefit Determination involves a medical condition for which the timeframe for completion of an expedited internal appeal under the interim final regulations would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function and you have filed a request for an expedited internal appeal; or The Adverse Benefit Determination concerns an admission, availability of care, continued stay, or health care item or service for which you received emergency services, but have not been discharged from a facility. Preliminary review. Immediately upon receipt of the request for expedited external review, the Claims Administrator must determine whether the request meets the reviewability requirements set forth in the Standard External Review section above. The Claims Administrator must immediately send you a notice of its eligibility determination that meets the requirements set forth in that section. Referral to the IRO. Upon a determination that a request is eligible for expedited external review following the preliminary review, the Claims Administrator will assign an IRO pursuant to the requirements set forth in the Standard External Review section. The Claims Administrator must provide or transmit all necessary documents and information considered in making the Adverse Benefit Determination to the assigned IRO electronically or by telephone or facsimile or any other available expeditious method. The assigned IRO, to the extent the information or documents are available and the IRO considers them appropriate, must consider the information or documents described above under the procedures for standard review. In reaching a decision, the assigned IRO is not bound by any decisions or conclusions reached during the Claims Administrator's internal claims and appeals process. Notice of Final External Review decision. The Claims Administrator's contract with the assigned IRO must require the IRO to provide notice of the final external review decision, in accordance with the requirements set forth in the Standard External Review section, as expeditiously as your medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request for an expedited external review. If the notice is not in writing, within 48 hours after the date of providing that notice, the assigned IRO must provide written confirmation of the decision to you and the Claims Administrator. 75

79 Exhaustion of Review Process For a standard internal review, you have the right to request external review once the internal review process has been completed and you have received the Adverse Benefit Determination. For expedited internal review, you may request external review simultaneously with the request for expedited internal review. The IRO will determine whether or not your request is appropriate for expedited external review or if the expedited internal review process must be completed before external review may be requested. You will be deemed to have exhausted the internal review process and may request external review if the Claims Administrator waives the internal review. In any event, you will not have any right to bring any action in any court more than 180 days after the Claims Administrator gives you a final decision on review. If you have any questions on the claims or appeals procedures, contact the Claims Administrator. If you feel the Plan has not complied with the claims and appeals procedures, there are steps you can take to enforce your rights. See Your ERISA Rights in the Administrative Information section. 76

80 McDONALD'S VISION SUPPLEMENT PLAN How the Vision Supplement Plan Works The Vision Supplement Plan helps you cover the cost of materials (such as eyeglasses and contacts) that are not otherwise covered by your medical plan for you and any eligible Dependents that you elect to cover under the Vision Supplement Plan. If you enroll in the Vision Supplement Plan, you will receive a vision care card from EyeMed Vision Care, the Vision Supplement Plan administrator. EyeMed provides prescription eyewear through a network of Providers. Because participating Providers can change, you should verify if your Provider is in the network before your receive services. To verify a Provider s participation in the network, you can: Visit AccessMCD. Call the EyeMed Vision Care member services at (866) Visit the EyeMed Vision Care website at Choose Access from the list of Provider network options. To receive benefits under the Vision Supplement Plan within the EyeMed network: Visit or call one of the participating providers in the network. To find a network Provider in your area, call EyeMed at (866) and follow the system prompts. Representatives are available Monday Saturday, 7:00 a.m. to 10:00 p.m. CT, and on Sunday from 10:00 a.m. to 7:00 p.m., CT. Through AccessMCD, link to the Vision Supplement Provider Directory site. Identify yourself as a Vision Supplement Plan participant by providing your identification card and your identification number. Receive your eyewear materials. (No claim forms needed but a valid prescription is required.) For your covered family members to receive benefits you must have your eligible Dependent data updated with McDonald s Service Center. The McDonald s Service Center will verify eligibility and communicate it to EyeMed who will then authorize appropriate benefits. You can also obtain prescription eyewear through a Provider who is out-of-network. To receive benefits out-ofnetwork: Visit your out-of-network Provider. Pay the Provider in full for the eyewear materials. For reimbursement based on the out-of-network benefit schedule shown below, call the EyeMed Customer Service Center at (866) to verify eligibility. Obtain a claim form from the EyeMed website or by calling them. Mail the completed claim form with a copy of your itemized bill to : EyeMed Vision Care Attn: OON Claims P.O. Box 8504 Mason, OH You must submit your claim within one year after the original date of service at the out-of-network provider s office. NOTE: The Vision Supplement Plan is for your prescription eyeglasses and contact lenses, not your vision exams, which are covered under your Medical Plan. See Vision Exam under the Covered Services section. 77

81 Basic Benefits Benefit when you use Providers in the network: Eyeglass Frames Covered at 100% up to $150 20% off amount over $150 Standard Plastic Lenses Single Vision Covered at 100% Bifocal Covered at 100% Trifocal Covered at 100% Lens Options Member Cost: Reimbursement amount when you use out-of-network Providers Up to $65 Up to $150 Up to $35 Up to $55 Up to $75 Reimbursement amount for Guam - all Providers Retail Retail Retail UV Treatment $15 N/A Retail less $15 Solid or Gradient Tints $15 N/A Retail less $15 Standard Plastic Scratch Coating $15 N/A Retail less $15 Standard Polycarbonate $0 $5 Retail Standard Progressive lens $0 $55 Retail Premium Progressive lens 80% of retail, less allowance $55 70% of retail of $120 Standard Anti-reflective Coating $45 N/A Retail less $45 Polarized 20% off retail N/A 20% of Retail Other Add-Ons 20% off retail N/A 20% of Retail Contact Lenses Materials Only Conventional Disposable Medically Necessary Laser Vision Correction Lasik or PRK Covered at 100%, up to $120 15% off amount over $120 Covered at 100%, up to $120 Covered in full 15% off retail or 5% off promotional price Up to $100 Up to $100 Up to $100 N/A Up to $120 Up to $120 Retail N/A The applicable benefit amount may only be used once per Calendar Year for any one of the following: one pair of eyeglasses or one pair of non-disposable contacts or one purchase of disposable contacts. If you use the benefit amount for disposable contact lenses, the benefit applies to the initial purchase of disposable contacts in a Calendar Year for up to the benefit limit. Additional purchases of disposable lenses in the Calendar Year are not covered. Benefits cannot be used in conjunction with other discounts or promotions. You will also receive a 40% discount off complete pairs of additional eyeglass purchases. There is a 15% discount on conventional contact lenses after the initial allowance is exhausted. There is no discount off disposable contact lenses once your Plan benefit has been used. You can also receive a 20% discount on items not covered by the Plan at network Providers. This discount cannot be combined with other discounts or promotions and is not applicable to Provider professional services or contact lenses. Mail Order Contact Lens Replacement Program The contact lens replacement program offers a convenient and economical alternative when purchasing additional sets of contact lenses. This is most applicable with the purchase of disposable lenses once your original prescription has been filled. The program allows you to buy the brand name contact lenses your Physician prescribes, via the internet. This is not part of the in-network benefits offered by EyeMed so you will be responsible for the entire cost of the order, plus any shipping 78

82 charges. Lenses are mailed to your home. Call (800) or log on to for more information and to order your lenses. Laser Vision Correction Members receive a 15% discount off the retail price or 5% off any promotional price of LASIK or PRK laser vision correction procedures. LASIK and PRK correction procedures are provided by the U.S. Laser Network, owned by LCA-Vision. Please note that since LASIK or PRK vision correction is an elective procedure, performed by specially trained Providers, this discount may not always be available from a Provider in your immediate location, so members should first call (877) for the nearest facility and to receive authorization for the discount. Exclusions Benefits are not provided for services or materials arising from: Orthoptic or vision training, subnormal vision aids and any associated supplemental testing. Aniseikonic lenses. Medical and/or surgical treatment of the eye, eyes or supporting structures. Any eye or vision examination, or any corrective eyewear required by a policyholder as a condition of employment. Safety eyewear. Services provided as a result of any Workers Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof. Plano (non-prescription) lenses and/or contact lenses. Non-prescription sunglasses. Two pair of glasses in lieu of bifocals. Services or materials provided by any other group benefit plan providing vision care. Services rendered after the date a Covered Person ceases to be covered under the policy, except when vision materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order. Lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next Calendar Year when vision materials would next become available. Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Certain brand name vision materials in which the manufacturer imposes a no-discount practice are excluded from coverage. Benefit allowances provide no remaining balance for future use within the same Calendar Year. To verify that a service or material is covered, you should contact EyeMed at (866) Coordination of Benefits If the covered individual is covered under more than one vision care plan, the Vision Supplement Plan is primary under all circumstances. If the covered individual is covered under more than one vision plan administered by EyeMed, however, the plan under which the covered individual is covered as an Employee is primary. If the covered individual is a dependent child, the plan of the parent whose birthday occurs earlier in the Calendar Year is primary. If a Claim Is Denied If you have questions concerning the denial of a vision claim or want to appeal a denied vision claim, contact EyeMed. For information on appealing a claim that relates to eligibility to participate in the Vision Supplement Plan, see the Applying for Benefits section. 79

83 McDONALD S DENTAL PLAN HIGHLIGHTS Calendar Year Maximum for All Preventive, Diagnostic, Therapeutic, General and Major Services: $1,500 Calendar Year Deductible: Per Covered Person - $100 For two or more Covered Persons -$200 Preventive services: Exam, cleaning and bitewing X-rays twice a year Fluoride treatments (children under 14, once a year) Sealants (children under 26)* Space maintainers (children under 14) 100% of R&C, no Deductible 100% of R&C, no Deductible 100% of R&C, no Deductible, $200 lifetime limit per child 90% of R&C, no Deductible Basic and Major Services: 80% of R&C, after Deductible Orthodontia** Lifetime Orthodontia Deductible Per Covered Person Coinsurance Level Lifetime Orthodontia Maximum Benefit per Covered Person $100 50% of R&C, after Deductible $2,000 *Charges do not count towards the Calendar Year Deductible or $1,500 Calendar Year maximum. **Orthodontia expenses will be considered as they are incurred and treatment has been rendered. 80

84 DENTAL COVERED EXPENSES If you elect Dental Plan coverage, your dental benefits provide payment for a wide range of dental expenses charged to you or your eligible Dependent by a Dentist or Physician while covered. BCBSIL Dental PPO BCBSIL maintains the BlueCare Dental PPO network, a network of dentists who have entered into an agreement with BCBSIL to provide services at negotiated rates. You are not required to use a dentist in the Dental PPO, and you will not receive a lower level of benefits for using a dentist outside the Dental PPO network. However, if you do use a dentist in the Dental PPO network, the dentist s fees for your visit will be based on the network negotiated rates, which are generally lower than the fees you would pay for a dentist not in the network. To find a dentist in the Dental PPO network, use the Provider Finder at Be sure to present your Plan ID card to get the negotiated rate for your visit. For out-of-network dental expenses, the Plan will only cover R&C charges for dental treatment. If the charges are greater than R&C, you will have to pay the difference (in addition to your Coinsurance and Deductible). Dental Health Maintenance Organization (DHMO) In Hawaii and Guam, a Dental Health Maintenance Organization (DHMO) may be available as a Dental Plan alternative. If you work at a location that has DHMO options, contact the McDonald s Service Center for details. Employees in Guam will only have the choice of the Netcare DHMO, because the BCBSIL network for the McDonald s Dental Plan is not available in Guam. Once you receive the information, you will have the opportunity to choose between the DHMO and the Dental Plan. DHMO participants are required to obtain care from the Providers of dental services who are affiliated with the DHMO. The DHMO establishes rates every year. McDonald s and you share contributions for the dental care service you receive through the DHMO. These rates can change from time to time. For the rates applicable to DHMOs in your area, please contact the McDonald s Service Center. If you choose a DHMO, the Dental Plan provisions that follow will not apply to you. Instead, the DHMO will send you a description of your dental benefits under the DHMO, as well as the claims and appeal process for those benefits. You should keep that description of benefits with this SPD for a complete description of your dental rights and benefits under the Dental Plan. 81

85 DENTAL PLAN PROVISIONS Deductibles A Deductible is the money you must spend each Calendar Year for basic and major covered charges before the Dental Plan begins paying benefits. The amount of your Deductible for each Calendar Year per Covered Person is $100. If you have family coverage under the Dental Plan, the annual Deductible for 2 or more Covered Persons is $200. Your annual Deductible for 2 or more Covered Persons is met when all of the family s basic and major Covered Charges, added together, reach the Deductible amount, with no single family member getting credit for more than the individual Deductible for one Covered Person. In other words, once a covered family member has met the individual Deductible for one Covered Person for the Calendar Year, none of the basic or major Covered Charges he or she has after that count toward meeting the Deductible for 2 or more Covered Persons for that Calendar Year. The Deductible does not apply to preventive services or to charges for emergency services. Annual Maximum The Dental Plan pays an annual maximum benefit of $1,500 per Covered Person. Covered Charges Covered Charges are those expenses listed below that are incurred for necessary dental care and treatment due to one of the following: Dental disease. Dental defect. Accidental Injury to the teeth or mouth, if the tooth is not sound. Routine preventive dental services, as specifically listed below, are also included as covered charges. How Covered Charges Are Calculated In general, the Dental Plan pays for dental treatment that begins after you or your Dependent becomes covered. The person must be covered on the date dental treatment is received. Most dental treatment is considered to have been received on the date the work is done. However, there are some kinds of treatment that take more time to complete. In these cases, treatment will be considered to have been received on the date shown below: For fixed bridgework, crowns, inlays, onlays and gold restorations the date the tooth or teeth are first prepared. For full or partial removable dentures the date the impression is taken. For orthodontic treatment the date bands are inserted. For Root Canal Therapy the date the tooth is opened. Alternate Procedures The possibility of an alternate treatment can also affect the amount of the Covered Charge. There is often more than one way customarily used by Dentists to treat a dental problem. Different materials or procedures may be used to correct the same problem. For example, a tooth could be repaired with an amalgam filling or with a more expensive cap (crown) or gold filling. Similarly, an extracted tooth could be replaced with a partial denture, fixed bridgework, or a more expensive implant. 82

86 The Dental Plan will allow, as Covered Charges only, the least expensive services and supplies which are appropriate and meet acceptable dental standards. You and the Dentist may decide you want the more expensive treatment. If so, you must pay the charges which are greater than the Covered Charge for the less expensive appropriate treatment. Because the Dental Plan has an alternate procedures provision, it is important for you to use a Pre-Determination of Benefits (see below), which tells you how much the Dental Plan will pay for the treatment. Covered Charges for Preventive Services Covered Charges for preventive services and supplies are as follows, not subject to the Deductible: Preventive services covered at the 100% Coinsurance level include expenses for the following: Routine oral exams twice per Calendar Year. Routine cleaning and periodontal prophylaxis, twice per Calendar Year. Bitewing X-rays twice per Calendar Year. Fluoride treatments for a child's teeth once each Calendar Year. The child must be under age 14. Sealants - applied to the permanent molars of a child under the age of 26. There is a $200 maximum Lifetime benefit. Preventive services covered at the 90% Coinsurance level include expenses for the following: Space maintainers and their fitting for a child under age 14 to replace primary teeth. (Appliance used to keep teeth from moving into the space left when a tooth is extracted or lost.) Covered Charges for Emergency Services Covered Charges are paid at a 90% Coinsurance level and not subject to the Deductible for emergency treatment for dental pain when no other treatment but X-rays is given. If other treatment is given, payment will be made only for the other treatment. Covered Charges for Basic and Major Services Covered Charges for basic and major dental services are paid at an 80% Coinsurance level, after satisfaction of the Deductible for the Calendar Year. These Covered Charges include expenses for the following: Diagnostic Services and Supplies: Full mouth X-rays once every 3 years. X-rays and lab tests for a diagnosis or to check progress of a treatment. Fillings: Silver (amalgam), silicate, plastic, porcelain and composite fillings. Therapeutic Services and Supplies: Root Canal Therapy (endodontic treatment). Treatment of gums and mouth tissues (periodontic treatment), excluding periosurgery. Simple extractions of one or more teeth. Extractions involving oral surgery and cutting procedures are covered under the Medical Plan. Antibiotic drugs which are injected by a Dentist or Physician. Treatment of TMJ (Temporomandibular Joint) syndrome. TMJ is a limited benefit under the Dental Plan. Office visits associated with the treatment and appliances are covered for TMJ, subject to the annual maximum. Restorative Services and Supplies: Crowns, inlays and onlays, subject to the following conditions: 83

87 Charges for these restorations are covered only if the tooth cannot be repaired with a less expensive type of filling. If the tooth can be repaired by a less expensive method, only that charge will be covered. Charges for replacement crowns and gold fillings are covered only if the old crown or filling is over 5 years old and cannot be made serviceable. A permanent crown may replace a temporary one if the tooth was prepared while the patient was covered by the Dental Plan. In this case, charges for both are limited to the charge for the permanent one. Prosthetic Services and Supplies (Repairs and Rebasing): Repairs to broken crowns, inlays, onlays, bridgework and dentures. This does not include adjustments made to new dentures or bridgework during the first 6 months after they are installed. Those charges are considered to be included in the cost of the new denture or bridgework. Extra charges are not covered. Rebasing or relining dentures which are over 6 months old. If the benefit pays for a new denture, it will not pay to rebase or reline the old denture. Adding teeth to fixed bridgework or partial dentures to replace missing natural teeth. The teeth that are being replaced must be lost while the person is covered. Dental implants, if an implant is the most appropriate treatment alternative and meets acceptable dental standards. Prosthetic Services and Supplies (Dentures and Fixed Bridges): Full or partial dentures, fixed bridgework or adding teeth to an existing denture to replace missing natural teeth. The teeth that are being replaced must be lost while the person is covered under this Dental Plan. Full or partial dentures and fixed bridgework to replace an existing denture or bridge that cannot be made serviceable. The existing denture or bridge must be over 5 years old. Charges for special techniques or precision attachments are not covered. Charges for any special work that you ask to have done on a standard denture are not covered. Charges made for adjustments to new dentures or bridgework during the first 6 months after they are installed are not covered. Those charges are considered to be included in the cost of the new denture or bridgework. Extra charges are not covered. A permanent denture may replace a temporary one, provided one or more of the replaced teeth have been extracted while covered by the Dental Plan. In this case, charges for both are limited to the charge for the permanent one. 84

88 ORTHODONTIA BENEFITS The orthodontia benefit provides treatment for you and your Dependents covered under the Dental Plan. Lifetime Deductible, Coinsurance Level and Maximum Benefit The amount of your Deductible for orthodontia per Covered Person is $100 for the Covered Person s Lifetime. The Dental Plan pays 50% of R&C covered charges after the Deductible is satisfied. There is a Lifetime maximum benefit per Covered Person for orthodontia expenses of $2,000. Covered Charges Covered Charges are R&C charges for the following services performed by a Dentist for straightening teeth: Diagnostic procedures. Appliances to realign the teeth. These Covered Charges will be included only if both of the following conditions are met: The first active appliance is installed while the person is covered. The Dentist diagnoses one of the following problems: The upper teeth protrude over the lower teeth. There is an open bite (front upper and lower teeth do not meet). The gum area is too large or small for the teeth (arch length discrepancy). Teeth are in crossbite (extreme bucco-lingual version of teeth). Charges for orthodontic treatment that are in excess of $4,000 plus the Lifetime Deductible will not be counted as covered charges. Payment Sequence Covered Charges are reimbursed as they are incurred and treatment has been rendered. BCBSIL will pay for services received based on the charges submitted, at the 50% Coinsurance level after the Lifetime Deductible has been met. A maximum initial fee reimbursement will not exceed 25% of the total R&C covered charges. It is the Employee s responsibility to submit copies of the Provider s statement identifying the patient, the services rendered and the dates of services. NON-COVERED DENTAL EXPENSES In general, the Plan does not cover dental expenses that would be excluded for the reasons listed in Non-Covered General Medical Expenses. In addition, the following specific services and supplies are not covered under the Dental Plan: Accidental Injury to the teeth or mouth, if the tooth is sound or unnatural (i.e., bridges, dentures, etc.). These expenses are covered under the Medical Plan. Athletic mouth guards. General anesthetics for treatment of gums or oral surgery. These expenses are covered under the Medical Plan. The Medical Plan considers local anesthetics as included in the charges for treatment. Additional charges for local anesthetics are not covered. For those in an HMO Medical Plan, benefits for general anesthetics for treatment of gums or oral surgery will not be payable since no coverage will be available for general anesthetic for treatment of gums or oral surgery under both the McDonald s Dental and the HMO Medical plans. Bleaching of teeth. Charges for crowns and fillings not listed as covered charges in this booklet. Crowns, inlays, onlays and veneers needed due to abrasion and attrition. Facings or veneers on molar crowns or molar false teeth. Filling materials, crowns and veneers used in conjunction with closing spaces between teeth. 85

89 Oral surgery and cutting procedures, including surgical extractions of teeth. These may be covered under the Medical Plan. For those in an HMO Medical Plan, benefits for oral surgery will not be payable since no coverage will be available for oral surgery under both the McDonald s Dental and the HMO Medical plans. OSHA fees and/or infection control fees and materials. Replacement of congenital missing teeth (teeth never developed after birth) or teeth extracted prior to coverage. Sealants for adults. Training or supplies used to educate people on the care of their teeth. Treatment by someone other than a Dentist or Physician, or dental technician under the direction of a Dentist or Physician. Work done to improve appearance (cosmetic treatment) or to increase vertical dimension of face. Injury caused by war or intentional armed conflict. Charges for failure to keep a dental appointment. WHEN DENTAL COVERAGE ENDS You and your Dependents coverage under the Dental Plan will stop under the circumstances identified in the "When Medical, Vision Supplement and Dental Coverage Ends" section and "Continuation of Coverage While on Leave" section. Under certain circumstances, you may be eligible to purchase replacement coverage as described in the "Continuation of Coverage under COBRA" section. COORDINATION OF DENTAL BENEFITS If you or your Dependents have dental coverage elsewhere, coverage under the Dental Plan is coordinated with your other coverage. See the "Coordination of Benefits" section. APPLYING FOR BENEFITS See the Applying for Benefits section under the Medical Plan for the procedure for applying for Dental benefits. 86

90 PRIVACY RULES YOUR INFORMATION. YOUR RIGHTS. OUR RESPONSIBILITIES. This notice describes how medical information about you may be used and disclosed and how you can get access to this information under the McDonald s Corporation Health Plan (Gold, Silver and Bronze Plans and Dental Plan) and the Employee Resource Connection. Please review it carefully. Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get a copy of health and claims records You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct health and claims records You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this. We may say no to your request, but we ll tell you why in writing within 60 days. Request confidential communications You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will consider all reasonable requests, and must say yes if you tell us you would be in danger if we do not. Ask us to limit what we use or share You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say no if it would affect your care. Get a list of those with whom we ve shared information You can ask for a list (accounting) of the times we ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated You can complain if you feel we have violated your rights by contacting the Privacy Official. See Privacy and Security Officials below. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C , calling (877) , or visiting 87

91 We will not retaliate against you for filing a complaint. Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: Share information with your family, close friends, or others involved in payment for your care. Share information in a disaster relief situation. If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission: Marketing purposes. Sale of your information. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Help manage the health care treatment you receive We can use your health information and share it with professionals who are treating you. Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services. Run our organization We can use and disclose your information to run the Plan and contact you when necessary. We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans. Example: We use health information about you to develop better services for you. Pay for your health services We can use and disclose your health information as we pay for your health services. Example: We share information about you with your dental plan to coordinate payment for your dental work. Administer your plan We may disclose your health information to your health plan sponsor for plan administration. Example: McDonald s contracts with BCBSIL to administer the Plan, and BCBSIL provides McDonald s with certain statistics to explain the premiums we charge. How else can we use or share your health information? We are allowed or required to share your information in other ways usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: Help with public health and safety issues We can share health information about you for certain situations such as: Preventing disease. Helping with product recalls. 88

92 Reporting adverse reactions to medications. Reporting suspected abuse, neglect, or domestic violence. Preventing or reducing a serious threat to anyone s health or safety. Do research We can use or share your information for health research. Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we re complying with federal privacy law. Respond to organ and tissue donation requests and work with a medical examiner or funeral director We can share health information about you with organ procurement organizations. We can share health information with a coroner, medical examiner, or funeral director when an individual dies. Address workers compensation, law enforcement, and other government requests We can use or share health information about you: For workers compensation claims. For law enforcement purposes or with a law enforcement official. With health oversight agencies for activities authorized by law. For special government functions such as military, national security, and presidential protective services. Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: Changes to the Terms of This Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our website, and we will mail a copy to you. Other Information Organized Health Care Arrangement For purposes of these privacy rules, the Medical Plan, Dental Plan, Employee Resource Connection, Healthcare Spending Account Plan and the Retiree Medical Plan are considered an Organized Health Care Arrangement. This means that these Plans may need to share protected health information with each other in order to manage their operations. However, the Plans will only share your protected health information with each other as is necessary for treatment, payment or health care operations of these Plans (as these terms are described below). Disclosure of Dependent Information Solely for purposes of allowing your Spouse or Domestic Partner to discuss your claims under the Plan and vice versa, the Plan will assume that you and your Spouse or Domestic Partner have designated each other as personal representatives, unless elected otherwise in writing. Also, the Plan will assume that your college-age Dependents have designated their parents as their personal representatives, unless they elect otherwise in writing. To elect otherwise, you, your Spouse or Domestic Partner and/or college-age Dependents should obtain a form from the McDonald s Service Center. Please note that this election applies only to communications with the McDonald s Service Center, not business associates. 89

93 Psychotherapy Notes We must get your written consent before using or disclosing any psychotherapy notes about you from your psychotherapist, using or disclosing protected health information for marketing, or selling your protected health information. Disclosure to Family Members or Relatives We can disclose your protected health information to family members or other relatives and close friends if the information is directly relevant to the family or friend s involvement with your care or payment for that care, and you have either agreed to the disclosure or, if possible, you have been given the chance to object to such disclosure and have not objected. Adequate Separation between the Plan and the Plan Sponsor Only the following Employees may be given access to protected health information: The Plan Administrator (McDonald s Corporation Welfare Plan Administrative Committee). The Privacy Official. The Security Official. Corporate Executive Vice President and Chief Human Resources Officer. Corporate Vice President, Global Total Compensation. U.S. Senior Vice President Human Resources. All McDonald s Service Center Employees. Legal, accounting and information system personnel to the extent they perform functions with respect to the Plan. Employees of the Global Benefits Department of the Company to the extent they perform functions with respect to the Plan. Employees of the Benefits and Compensation Department of McDonald s USA, LLC to the extent they perform functions with respect to the Plan. Those Employees designated by the individuals listed above to assist in Plan administration. Privacy and Security Officials The current Privacy Official is Haydee Olinger, Vice President, Global Compliance. The current Security Official is Marc Varner, Senior Director IT Security. If you believe your privacy rights have been violated, you may file a written complaint with the Privacy Official at McDonald s Corporation, Business Integrity Liaison, P.O. Box 4567, Oak Brook, IL Contact Information If you wish to make a request listed under Your Privacy Rights, you should contact the McDonald s Service Center if your request relates to protected health information held by the McDonald s Service Center at: McDonald s Service Center Dept McDonald s Drive Oak Brook, IL (877) If your request relates to protected health information held by one of the business associates listed below, you should contact that business associate directly: Blue Cross and Blue Shield of Illinois P.O. Box Chicago, IL (800) CVS Caremark P.O. Box Richardson, TX (866) ComPsych NBC Tower, 13 th Floor 455 N. Cityfront Plaza Drive Chicago, IL (888) PayFlex Systems USA, Inc. Attn: Reimbursement Accounts P.O. Box 3039 Omaha, NE (800)

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96 EMPLOYEE RESOURCE CONNECTION, GROUP INSURANCE, SPENDING ACCOUNTS

97 WHO IS ELIGIBLE FOR BENEFITS IN THIS SECTION: Full & Part-Time Staff Restaurant Employees in the following positions: General Manager Department Manager Certified Swing Primary Maintenance 93

98 EMPLOYEE RESOURCE CONNECTION The Employee Resource Connection is a variety of services and information that help you manage your everyday life. Whether you are looking for day care or elder care, planning an event, preparing a household budget, or in need of general legal information or in need of counseling as you work through a stressful situation the Employee Resource Connection is a resource for you. The Employee Resource Connection services are all completely confidential. These services are all provided through the GuidanceResources program offered by ComPsych, an outside company, to ensure your complete privacy. Eligible Employees You are an Eligible Employee if you are a Full-Time or Part-Time Staff, Restaurant General Manager, Department Manager, Certified Swing Manager or Primary Maintenance Employee on the U.S. payroll of McDonald s or another Employer. Full- Time means you are regularly scheduled to work at least 35 hours per week. Part-Time means you are regularly scheduled and working at least 20 hours per week. In the event of a traumatic situation that involves restaurant employees, Employee Resource Connection services will be offered as needed regardless of full-time management status. Enrollment Enrollment in the Employee Resource Connection is automatic for you and your eligible Dependents and does not require participation in any other McDonald s benefit plan. McDonald s pays the full cost of the Employee Resource Connection. (See the definition of Dependent in the Enrollment and Cost For Medical, Vision Supplement and Dental section.) When Does Coverage Begin? Coverage begins on the date you become an Eligible Employee. How the Employee Resource Connection Works The Employee Resource Connection is available through the GuidanceResources program administered by ComPsych, which is staffed by experienced professionals who provide confidential counseling services, as well as financial, work/life and legal services. These experts can help you sort through issues and develop a solution you may not have considered on your own. The services provided through the Employee Resource Connection are strictly confidential. ComPsych will not release any information about you or your family members unless you give written permission or unless the law requires it. How to Reach the GuidanceResources Program You can reach the GuidanceResources program 24 hours a day, seven days a week. When you or a family member wants to use the counseling, financial, legal or other work/life services, simply: Call GuidanceResources toll-free at (888) Go to GuidanceResources Online at and enter the McDonald s ID number MCD721 to register as a new user on your first visit. Counseling Services You can call GuidanceResources anytime day or night toll-free at (888) A GuidanceResources counselor will listen to your concerns and obtain a referral for you to talk to an expert counselor located in your area. During the appointment, the counselor will discuss your situation and help you develop a plan of action. You can visit the GuidanceResources counselor up to 8 times at no cost to you. 94

99 A GuidanceResources counselor can help you and your Dependents deal with a variety of concerns, including: Depression. Marital and family conflicts. Drug and alcohol abuse. Major life changes. Relationship issues. Anxiety and stress. Eating disorders. Coping with grief and loss. Problems of adolescence. Aging parents. Some problems, due to their nature or complexity, may require outside professional support over a period of time beyond 8 sessions. In these cases, the GuidanceResources counselor may recommend additional services or the services of specific providers who have the expertise to assist you with your particular situation. These services may be covered under your medical plan. If you are participating in the Gold, Silver or Bronze Plan, these additional services may be covered under the Mental Health/Substance Abuse Program. Refer to the Mental Health/Substance Abuse Program section of the SPD for an explanation of those benefits and the precertification requirements that apply to those benefits. Work/Life Programs GuidanceResources specialists offer practical assistance through telephone consultation, referral information and educational literature. Specialists are available to provide assistance on a wide range of issues such as: Finding and evaluating quality daycare. Finding and evaluating quality care for elderly parents. School selection for the relocating employee. Planning for your child s college education. Understanding programs such as Medicare and Medicaid. Callers receive detailed resource packages containing referral information on community resources, available openings in programs and guidelines for evaluating facilities such as: Daycare centers and after school programs. Public and private schools and tuition assistance. Geriatric assessment clinics. Assisted living and other housing options for the elderly. Financial Services The GuidanceResources program offers you unlimited telephone access to certified public accountants, certified financial planners and other financial professionals who are trained and experienced in handling personal financial issues. They can provide you with information and answer questions on issues such as family budgeting, credit problems, tax questions, investment options, money management and retirement programs. The GuidanceResources financial specialists do not offer specific advice on your financial situation. For financial advice, you should consult with your personal financial advisor. Legal Services The GuidanceResources program provides you with unlimited telephone consultation with attorneys who are trained and dedicated to providing general legal information to clients with such issues as divorce, bankruptcy, family law, real estate purchases and wills. The GuidanceResources attorneys do not provide legal advice. If you need legal representation or extended assistance that cannot be provided through general information by phone, GuidanceResources professionals can provide referrals to a network of local attorneys who offer services at a 25% discount on fees. 95

100 Visiting GuidanceResources Online GuidanceResources Online can help you obtain personal information for your life issues. At GuidanceResources, you can: Obtain information about personal, emotional and life issues. Read help sheets with helpful hints on hundreds of topics. Review frequently asked questions. Get book recommendations. Use online tools to help you with your needs. To access GuidanceResources Online, simply log onto and enter the McDonald s ID number: MCD721. When Does Coverage End? You and your Dependents access to the Employee Resource Connection services ends on the earliest of the following dates: The last day of the month in which (i) you retire or otherwise end your employment, (ii) you are transferred to a class of Employees that is not eligible to participate in the Employee Resource Connection or (iii) with respect to your Dependents, a Dependent loses Dependent status; or The day McDonald s discontinues the Employee Resource Connection. If you qualify for Long Term Disability benefits or COBRA, the Employee Resource Connection will continue at no cost to you throughout the applicable Long Term Disability or COBRA period. See the sections entitled Qualifying Events and When COBRA Coverage Can End Early in the COBRA section of the SPD. 96

101 YOUR GROUP INSURANCE PLAN Overview McDonald's provides insurance coverage under the McDonald s Corporation Group Insurance Plan, including survivor benefits through Life, AD&D, Business Travel Accident and Long Term Disability Insurance. These benefits are referred to in this portion of the booklet as the Plan. 97

102 McDONALD S SURVIVOR BENEFITS HIGHLIGHTS The following chart summarizes your basic survivor benefits and available optional survivor benefits: Employee and Dependent Life Benefits Employee Basic Term Life* Employee Basic AD&D Employee Optional Term Life* Employee Optional AD&D Basic Dependent Life: Spouse or Domestic Partner Each Dependent Child Amount of Coverage 2 times your Base Annual Pay, rounded up to the next highest $1,000, for each benefit Your choice of 1-5 times your Base Annual Pay (in whole numbers), rounded up to the next highest $1,000 $10,000 $10,000 Optional Dependent Life Spouse or Domestic Partner Your choice of: $10,000 $15,000 $25,000 $50,000 Each Dependent Child Your choice of $ 2,500 $ 5,000 $10,000 $15,000 *Reduced to 65% of the original amount of coverage effective the January 1 st following the date you reach age 65. Basic Survivor Insurance Benefits Employee Basic Life - Pays a benefit to your beneficiaries if you die while covered. Employee Basic Accidental Death and Dismemberment (AD&D) - Pays an additional AD&D benefit if you die within 365 days of an injury due to an accident or suffer a covered physical loss within 365 days of injuries due to an accident. Business Travel Accident - Pays an additional benefit if you die from injuries resulting from an accident or suffer a physical loss due to an accident while traveling on company business within 365 days after the accident. Basic Dependent Life - Pays a benefit to you if your eligible Dependent child, Spouse or Domestic Partner dies while you are covered. Optional Survivor Insurance Benefits Optional Term Life - If elected, this coverage pays an additional benefit to your beneficiaries if you die while covered. This coverage includes an automatic Optional AD&D coverage. Optional Dependent Life - If elected, this coverage pays an additional benefit to you if your eligible Dependent child, Spouse or Domestic Partner dies while you are covered. 98

103 Eligible Employees You are an Eligible Employee if you are a Full-Time or Part-Time Staff, Restaurant General Manager, Department Manager, Certified Swing Manager or Primary Maintenance Employee on the U.S. payroll of McDonald s or another Employer. Full- Time means you are regularly scheduled to work at least 35 hours per week. Part-Time means you are regularly scheduled and working at least 20 hours per week. Enrollment Once you become an Eligible Employee, you do not have to enroll for basic survivor benefits (Employee Basic Life, Basic AD&D, Basic Travel Accident, Business Travel Accident and Basic Dependent Life). These benefits are automatic. However, you do have to enroll to be covered under the Optional Term Life Insurance benefits. To enroll, McDonald s must receive your completed enrollment form (available from the McDonald s Service Center or AccessMCD) prior to the date your survivor benefit coverage starts. (See When Does Coverage Start? below.) After the initial enrollment period has passed, enrolling for the first time or increasing your coverage requires special approval based upon showing evidence of insurability. If you apply for a change in coverage that requires showing evidence of insurability, your coverage change will be effective on the first of the month following approval of your application by Aetna. Please contact the McDonald s Service Center for further details. When Does Coverage Start? Your survivor benefit coverage starts on the first of the month after you complete one month of service in the eligible position (4 consecutive weeks of service if you reside in Hawaii), assuming you are Actively at Work on that date. If you were employed in a class of employees that are not Eligible Employees and you become an Eligible Employee, your basic survivor benefit coverage starts on the first day of the month following the date you complete the waiting period described above after becoming an Eligible Employee. However, your Optional Term Life coverage will start on that date only if you have enrolled for the coverage by that date. If you transfer to McDonald s from a benefits-eligible position at any other Employer (as defined in the Glossary), your service in the benefits-eligible position with those companies will count towards your waiting period under the Plan. If you are not Actively at Work on the date your coverage is to start, your coverage will take effect on the date you return to Active Work for Basic survivor coverage and the first day of the month after the date you return to Active Work for Optional survivor coverage. Cost of Plan As an Eligible Employee, McDonald s automatically provides you with Employee Basic Life, AD&D and Business Travel Accident coverage, as well as Basic Dependent Life coverage for your eligible Dependents. 99

104 EMPLOYEE LIFE INSURANCE BENEFITS EMPLOYEE BASIC LIFE INSURANCE BENEFITS If you are covered under the Employee Basic Life benefit, your beneficiaries will receive a benefit equal to 2 times your Base Annual Pay, rounded up to the next highest $1,000. "Base Annual Pay" means your annual base compensation not including overtime, bonus or any extra payments you receive from McDonald s. Because your life insurance benefits are tied to your Base Annual Pay, your benefit levels automatically change if your Base Annual Pay changes. The change will be effective on the day your pay changes. If you are not Actively at Work on the date you experience a change in your Base Annual Pay, the change in coverage will take effect on the day you resume Active Work. For hourly Employees, annual base compensation is computed in general as follows: hourly rate times 1,950 hours for Certified Swing, Primary Maintenance and Full-Time Staff Employees, hourly rate times 1,500 hours for Part-Time Staff Employees and hourly rate times 2,470 hours for Department Managers or Manager Trainees. Maximum Basic Life Insurance Benefit: $3,000,000 Funeral Planning Services Your Basic Life Insurance includes funeral planning services. It is offered through Everest Funeral Planning and Concierge Services, LLC. You can receive assistance in planning a funeral, which includes price comparisons and price negotiations, and arrange to have funeral expenses paid directly from the life insurance benefit. For more information on this benefit, you should speak with an Everest Funeral Planning and Concierge Service Advisor at (800) EMPLOYEE OPTIONAL TERM LIFE INSURANCE BENEFITS When you enroll for Optional Term Life Insurance, you are automatically insured for equal amounts of Employee Optional AD&D and you may elect to buy Optional Dependent Life Insurance. You must sign up to get this optional coverage and then you will pay an age-based monthly premium through payroll deductions. Cost of the Optional Term Life Plan The cost of optional coverage must be paid in full by the Employee. The cost of optional coverage depends upon your age and the amount of coverage you elect. The McDonald s Service Center can provide you with the costs by age. For this purpose, the age used is your age on December 31 st of the current calendar year. Amount of Your Optional Term Life Benefits You may purchase coverage equal to 1 to 5 (in whole numbers) times your Base Annual Pay rounded up to the next highest $1,000, to a maximum benefit of $2,000,000. If you die while this optional coverage is in force, your beneficiary will receive benefits from both the Employee Basic Life Insurance and Optional Term Life Insurance. For example, suppose your Base Annual Pay is $30,400 and you have elected Optional Term Life Insurance equal to two times your Base Annual Pay, rounded up to the next highest $1,000 ($61,000). If you die while this coverage is in effect, your death benefit would be calculated as follows: Basic Life Insurance Benefit $ 61,000 Optional Term Life Insurance Benefit $ 61,000 Total Benefit $122,

105 If you enroll for or increase your Optional Term Life coverage at a later time, subject to approval of insurability, coverage becomes effective as of the first day of the first month after your application has been approved. If you are not Actively at Work on that date, coverage becomes effective on the first day of the month after you return to Active Work. 101

106 DEPENDENT LIFE INSURANCE BENEFITS BASIC DEPENDENT LIFE INSURANCE BENEFITS Eligible Dependents If you are eligible for the Employee Basic Life benefit, you will automatically receive Basic Dependent Life coverage for your eligible Dependents. Your eligible Dependents are: Your Spouse or Domestic Partner Your unmarried children, up to age 26 who are dependent upon you for support and maintenance "Children" includes any of the following: Your natural child(ren). Your step-child(ren). Your Domestic Partner s child(ren). Your legally adopted child(ren) (including a child(ren) who has been placed for adoption). Children for whom you, your Spouse or your Domestic Partner are a legal guardian and who live with you and are dependent on you for support and maintenance. Your unmarried handicapped children, regardless of age, who are dependent on you for support and maintenance. Under the insurance policies for your Basic and Optional Dependent Life coverage, eligibility rules for Dependents may vary from state to state, depending on state law. Note specifically that Dependents in the state of Texas include grandchildren living with you and dependent on you for care and support. Grandchildren must be claimed by the Employee as a dependent for Federal income tax purposes at the time the Employee applied for the Dependent Life Benefits. Also, no person can be covered both as an Employee and as a Dependent and no person can be covered as a Dependent of more than one Employee under Basic and Optional Dependent Life coverage. Finally, a Dependent does not include an unborn or stillborn child. If you have questions about Dependent eligibility, contact the McDonald s Service Center. When Does Coverage Start? Your eligible Dependent(s) Basic Dependent Life coverage starts on the same day your Employee Basic Life coverage starts or, if later, the date that you acquire the Dependent(s). Cost of the Plan McDonald's pays the cost of your Basic Dependent Life coverage. Amount of Your Basic Dependent Life Benefits Spouse or Domestic Partner $10,000 Each Dependent child $10,000 OPTIONAL DEPENDENT LIFE INSURANCE BENEFITS Electing Optional Dependent Life Coverage and Effective Date of Coverage You may buy additional Dependent Life insurance for your eligible Dependents. If you are a newly eligible Employee, you must elect the Optional Dependent Life coverage prior to the date your Basic Life coverage starts. If you acquire a new Dependent after your Basic Life coverage begins, you must elect the Optional Dependent Life coverage within 31 days after 102

107 the date you acquire the new Dependent. In either case, if you are not Actively at Work on the date your Dependent becomes eligible for Basic Dependent Life coverage, you must elect Optional Dependent Life coverage on or prior to the date you return to Active Work. If you make a timely election, Optional Dependent Life coverage will become effective on the date your Basic Life Coverage starts, or, if later, for a newly acquired Dependent, the date you acquire the Dependent. If you are not Actively at Work on that date, coverage will start on the first day of the month after you return to Active Work. Late Elections If you do not make a timely election for the Optional Dependent Life coverage, your Spouse or Domestic Partner will be required to show evidence of good health in order to get the coverage. In any event, Dependent children will not be required to show evidence of good health. For a late election, Optional Dependent Life coverage for your children will become effective on the first day of the month after the date you request coverage. For your Spouse or Domestic Partner, Optional Dependent Life coverage will become effective on the first day of the month after Aetna approves the Optional Dependent Life coverage. Amount of Your Optional Dependent Life Benefits Spouse or Domestic Partner $10,000 $15,000 $25,000 or $50,000 Each Dependent Child until under age 26 $ 2,500 $ 5,000 $10,000 or $15,000 Who Pays for Coverage? You must pay the full cost of Optional Dependent Life coverage. The cost of Optional Dependent Life insurance coverage for your Spouse or Domestic Partner is based on your age and the amount of coverage you elect. The cost of Optional Dependent Life insurance coverage for your child is a flat rate based on what coverage level you elect. Your cost for this coverage will be the same regardless of the number of eligible Dependent children you cover under the Plan. The McDonald s Service Center can provide you with detailed Optional Dependent Life insurance cost information. 103

108 EMPLOYEE ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE EMPLOYEE BASIC AD&D INSURANCE If while insured you suffer a covered loss (including death) due to a covered accident within 365 days of that accident, your AD&D Insurance pays a benefit. Employee Basic AD&D Insurance Amount If you have AD&D coverage and die within 365 days of a covered accident from covered injuries sustained in that accident, your beneficiary is eligible to receive 2 times your Base Annual Pay (defined in the Employee Basic Life Insurance Benefits section), rounded up to the next $1,000, to a maximum of $3,000,000. This benefit is payable in addition to your Basic Life Insurance benefit. Change In Base Annual Pay As is the case with Employee Basic Life Insurance, when your pay increases, the amount of your AD&D Insurance increases automatically. If you are not Actively at Work on the date you experience a change in your Base Annual Pay, the change in coverage will take effect on the day you resume Active Work. Dismemberment Schedule The Employee dismemberment benefits are payable in addition to Employee Basic Life Insurance, if you suffer a covered physical loss as a result of an accident within 365 days of the accident, as follows: If you have this loss: This is the benefit: Loss of life 100% of full amount Loss of two or more hands or feet 100% of full amount Loss of sight of both eyes 100% of full amount Loss of one hand or one foot and sight in one eye 100% of full amount Loss of speech and hearing (in both ears) 100% of full amount Third degree burns covering 75% or more of the body 100% of full amount Loss of one hand or foot 75% of full amount Loss of sight in one eye 75% of full amount Loss of speech 50% of full amount Loss of hearing (in both ears) 50% of full amount Third degree burns covering 50% up to 75% 50% of full amount Loss of thumb and index finger of the same hand 25% of full amount No more than the employee s full Basic AD&D Insurance amount is payable for all losses resulting from one accident. Paralysis Schedule The following benefits are payable if you suffer a paralysis of a limb. Paralysis of a limb means total loss of use of a limb, which is determined by a competent medical authority to be complete and irreversible. If you have this loss: Quadriplegia Paraplegia Hemiplegia Uniplegia This is the benefit: 100% of full amount 66.67% of full amount 66.67% of full amount 25% of full amount 104

109 No more than the employee s full Basic AD&D Insurance amount is payable for all losses resulting from one accident. Maximum Basic AD&D Benefit: $3,000,000 EMPLOYEE OPTIONAL AD&D INSURANCE If you elected Optional Term Life Insurance, Optional AD&D Insurance is automatically provided for an amount equal to your Optional Term Life, according to the same schedules listed above for basic AD&D. Maximum Optional AD&D Benefit: $2,000,000 COMMON CARRIER BENEFIT The plan will pay a common carrier benefit, for a death that involves public transportation if: You die solely and as a direct result of an accident while boarding, alighting from, or traveling in a public conveyance; and Your death occurs within 365 days of the accident; and The conveyance is licensed for the transportation of passengers by a governmental authority that has jurisdiction over its registration; and A charge is made to use the conveyance. Common Carrier Benefit Payable: The benefit payable is an additional amount equal to your Basic AD&D Insurance amount (and Optional AD&D amount if applicable), up to the specified maximum of $500,000 if you die. EXCLUSIONS The Employee Basic and Optional AD&D Insurances do not cover losses from the following: Intentionally self-inflicted injury, suicide or any attempt thereat while sane or insane. Commission or attempt to commit a felony or an assault. Commission of or active participation in a riot or insurrection. 3 rd degree burns resulting from sunburn. Use of alcohol. Use of alcohol or intoxicants or drugs while operating any form of a motor vehicle accident will be deemed to be caused by the use of alcohol, intoxicants or drugs if it is determined that at the time of the accident you or your covered Dependent were: Operating the motor vehicle while under the influence of alcohol as a level which meets or exceeds the level at which intoxication would be presumed under the laws of the state where the accident occurred. If the accident occurs outside of the United States, intoxication will be presumed if the person s blood alcohol level meets or exceeds.o8 grams per deciliter; or operating the motor vehicle while under the influence of an intoxicant or illegal drug; or operating the motor vehicle while under the influence of a prescription drug in excess of the amount prescribed by the physician; or operating the motor vehicle while under the influence of an over-the-counter medication taken in an amount above the dosage instructions. Declared or undeclared war or act of war. Intended or accidental contact with nuclear or atomic energy by explosion and/or release. Ligature strangulation resulting from auto-erotic asphyxiation. Medical or surgical treatment: An infection which results directly from the injury. Surgery needed because of the injury. The injury must not be one which is excluded by the terms of this section. Air or space travel. This does not apply if a person is a passenger with no duties at all, on an aircraft being used only to carry passengers (with or without cargo.) 105

110 Illness, ptomaine or bacterial infection or bodily or mental infirmity. This exclusion does not apply if the loss is caused by: An infection which results directly from the injury. Surgery needed because of the injury. The injury must not be one which is excluded by the terms of this section. Voluntary ingestion of any narcotic, drug, poison, gas, fumes or poisonous gases unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage. ADDITIONAL AD&D INSURANCE BENEFITS Rehabilitative Therapy Benefits If you suffer an Injury which results in a dismemberment loss covered under the AD&D Insurance, the Insurance will pay an additional 20% of your full benefit for Rehabilitative Physical Therapy that is prescribed by the attending Physician or surgeon, subject to a maximum of $20,000. For purposes of these benefits, Rehabilitation means medical services, supplies, or treatment or hospital confinement (or part of a hospital confinement) that satisfies all of the following conditions: Are essential for physical rehabilitation required due to your covered accident. Meet generally accepted standards of medical practice. Are performed under the care, supervision or order of a physician. Prepare you to return to your previous or any other occupation. Coma Benefit If within 365 days from the date of a covered accident you are in a coma for at least 31 consecutive days, the AD&D Insurance will pay you a monthly benefit up to a maximum of 11 months. This monthly benefit is equal to 5% of your Basic AD&D death benefit amount (less the amount of any other benefit paid under the Plan for loss arising out of the same accident). After 11 months of payment, the Plan will pay you 100% of the remaining Basic AD&D death benefit amount in the 12 th month. In no event will the total amount paid to you for all benefits under the AD&D Plans exceed two times your Basic AD&D death benefit amount. If you are covered under Optional AD&D Insurance when you become entitled to the coma benefit described above, your Optional AD&D Insurance will also pay a monthly benefit equal to 5% of your Optional AD&D death benefit amount. In no event will this additional benefit exceed your Optional AD&D death benefit amount. The benefits described above will be payable for each month that you are in a continuous coma up to a maximum of 11 months. No coma benefit will be payable after the comatose condition ends, whether by death, recovery or any change of condition. Seat Belt/Airbag Benefit If you die as a result of a motor vehicle accident while operating or riding as a passenger in any private passenger motor vehicle designed for use primarily on public roads and at the time of the accident you were wearing a seat belt or lap shoulder restraint, your beneficiary will be entitled to receive an additional 10% of your full benefit amount under the AD&D Insurance, up to a maximum of $50,000. In addition, if you were positioned in a seat protected by a properly functioning and properly deployed Supplemental Restraint System (airbag), your beneficiary will be entitled to receive an additional 5% of your full benefit amount under the AD&D Insurance, up to a maximumbbenefit of $25,000. Verification of the use of a seat belt or lap shoulder restraint and that the airbag properly inflated upon impact at the time of loss is required in the official report of the accident through certification by the investigating officers or by other reasonable proof determined by the insurer. Also, in the case of a child, seatbelt means a child restraint as required by state law and approved by the National Highway Traffic Safety Administration, secured and used as recommended by the manufacturer. A seat belt or airbag benefit is not payable for any death caused by, contributed to, or resulting from a motor vehicle accident 106

111 in which the operator of the vehicle is intoxicated or under the influence of drugs or narcotics, unless prescribed by a Physician for a medical condition other than drug addiction. The determination as to whether the operator of a vehicle was intoxicated shall be made in accordance with the laws of the state in which the motor vehicle accident occurred. Exposure and Disappearance Coverage If you die or experience a physical loss which results directly and independently of all other causes* from unavoidable exposure to natural or chemical elements following a covered accident, your AD&D benefits will be paid according to the same death benefit and Dismemberment and Loss of Use Schedules as apply to your Basic AD&D Insurance. *The plan will pay an accidental death benefit if your body is not found, and no contrary evidence about the circumstances of your disappearance arises, within one year of the accidental disappearance, sinking or wrecking of a conveyance you or your covered dependent occupied. Home Alteration and Vehicle Modification Benefit If you suffer a covered injury or loss under the AD&D, the AD&D Insurance will pay up to an additional $10,000 of your full benefit for out-of-pocket expenses that are incurred by a member for necessary home and vehicle modifications that are needed to make your principal residence and/or personal motor vehicle accessible and usable following an accident that results in severance or paralysis. Medical Coverage Funding Benefit If you suffer an Injury or loss covered under the AD&D, your benefit will provide up to $300 per month/$3,600 per year, for up to 36 months to help pay for out-of-pocket expenses that are incurred by surviving dependents who elect to continue medical coverage under the Employer s COBRA option. Monthly Hospital Benefit If you suffer an Injury or loss covered under the AD&D, your benefit will provide a $2,500 monthly income benefit if you become confined to a hospital or convalescent facility for more than 30 days following an accident. The benefit is payable for each 30-day period of continuous confinement for up to a maximum of 12 months/$30,000. Education Benefit for Spouse and/or Child If you die as a result of an accident, an education benefit is payable for a Spouse and Dependent child at 5% of your Basic AD&D Insurance amount (and Optional AD&D amount if applicable) to a maximum of $5,000 per year, payable for up to 4 years. Child Care Benefit If you die as a result of a covered accident, a child care benefit is payable at 3% of your Basic AD&D Insurance amount (and Optional AD&D amount if applicable) to a maximum of $2,000 per year, payable for up to 4 years. Repatriation of Remains Benefit If you die as a result of an accident and the death occurs 200 or more miles outside of the principal residence, the benefit provides up to $5,000 to prepare and transport the body to a mortuary. 107

112 BUSINESS TRAVEL ACCIDENT INSURANCE BUSINESS TRAVEL COVERAGE If you are in an Eligible Class, you are automatically insured on the first day of work with McDonald s for business travel coverage. Schedule of Benefits Eligible Class Amount of Coverage ( Principal Sum ) Primary Maintenance, Certified Swing, Full-Time Staff and Full-Time Restaurant Management Employees $100,000 All Interns, Part-Time Employees, Restaurant Crew and Temporary Employees of McDonald's $100,000 Directors or above $200,000 Pilots $ 25,000 The total liability for all Employees involved in a single accident is $12,000,000. Your Spouse or Domestic Partner $ 25,000 Each Dependent Child $ 10,000 Conditions of Coverage If you, your Spouse and/or your Dependent Child(ren) die within 365 days of a Covered Accident while traveling on McDonald's business, your beneficiary is eligible to receive a benefit as shown in the Schedule of Benefits. A business trip begins when you leave home, work or another location on McDonald s business. It ends when you return home or to work (whichever occurs first). The benefit also covers: Short business stays of less than 365 days away from your permanent work location and Personal Deviations of up to 72 hours. (A Personal Deviation is an activity that is not related to or incidental to the purpose of your business travel, that occurs before, during or after the covered travel.) A Covered Accident is a sudden, unforeseeable, external event that results, directly and independently of all other causes in a Covered Injury or covered loss (including death) and meets all of the following conditions: 1. Occurs while the Covered Person is covered under this benefit; 2. Occurs under one of the conditions specified in these Conditions of Coverage; 3. Is not contributed to by disease sickness or mental of bodily infirmity; and 4. Is not otherwise excluded under the other provisions of this Business Travel Accident section. A Covered Injury is any bodily harm that results, directly and independently of all other causes, from a Covered Accident. If while insured you suffer a covered loss (including death) due to a covered accident within 365 days of that accident, your Business Travel Accident Insurance pays a benefit as shown in the schedule below. 108

113 Schedule of Covered Losses If you have this loss: Loss of Life Loss of Two or More Hands or Feet Loss of Sight of Both Eyes Loss of One Hand or One Foot and Sight in One Eye Loss of Speech and Hearing (in both ears) Quadriplegia Paraplegia Hemiplegia This is the benefit: 100% of the Principal Sum 100% of the Principal Sum 100% of the Principal Sum 100% of the Principal Sum 100% of the Principal Sum 100% of the Principal Sum 50% of the Principal Sum 50% of the Principal Sum Coma Monthly Benefit 1% of the Principal Sum Number of Monthly Benefits 11 When Payable At the end of each month during which the Covered Person remains comatose Lump Sum Benefit When Payable Loss of One Hand or Foot Loss of Sight in One Eye Loss of Speech Loss of Hearing (in both ears) Loss of Thumb and Index Finger of the Same Hand 100% of the Principal Sum Beginning of the 12th month 75% of the Principal Sum 50% of the Principal Sum 50% of the Principal Sum 50% of the Principal Sum 25% of the Principal Sum ADDITIONAL COVERAGE OFFERED UNDER BUSINESS TRAVEL ACCIDENT INSURANCE Commuting Benefit Cigna will pay the benefit shown in the Schedule of Benefits, subject to all applicable conditions and exclusions, if the Covered Person sustains a covered loss resulting, directly and independently of all other causes, from a Covered Accident that occurs while commuting directly to and from the Covered Person's home and the premises where he normally works. Exclusions: This benefit will not be payable for Covered Accidents that happen more than two hours after the Covered Person leaves his home or place of work unless it can definitely be shown that: The delay was caused by conditions beyond the control of the Covered Person; or More time was needed for normal direct commuting. Other exclusions that apply to this benefit are in the Exclusions section. Bomb Scare, Bomb Search or Bomb Explosion Benefit Cigna will pay the benefit shown in the Schedule of Benefits if the Covered Person suffers a covered loss resulting, directly and independently of all other causes, from a Covered Accident and all of the following conditions are met: The Covered Person is on the Employer s premises when the Covered Accident occurs; The Covered Accident is caused by or results from a Bomb Scare, Search or Explosion, as defined below; The Covered Person is an authorized participant of a team or squad engaged in a Bomb Search or related activity; and The Employer authorizes the Covered Person's participation and sanctions the Search. 109

114 Definitions for purposes of this benefit: Bomb means any real or dummy explosive device placed with intent to damage, scare, or cause injury. Scare means any real or false report of a Bomb on the Employer s premises. Search means any organized search for a reported Bomb. Explosion means any detonation of a Bomb on the Employer s premises which appears to have been intended to cause injury or unlawful property damage, whether or not the presence of the Bomb was reported before detonation. It does not include any act of declared or undeclared war in the United States or Canada, or acceptance of known explosives as cargo. Dependent Coverage Cigna will pay an Accidental Death and Dismemberment Benefit specified in the Schedule of Covered Losses if a Spouse, Domestic Partner or Dependent Child of the Covered Person suffers a covered loss which results, directly and independently of all other causes, from a Covered Accident that occurs: Within the time period specified in the Conditions of Coverage; and During a relocation trip or covered business travel or a covered activity for which the Employer pays part or all of the cost; and Under circumstances described in one of the Conditions of Coverage specified above. Benefits payable for a Dependent's covered loss will equal the applicable Principal Sum benefit amount shown in the Schedule of Benefits multiplied by the percentage applicable to the covered loss, as shown in the Schedule of Covered Losses. Carjacking Benefit Cigna will pay the benefit shown in the Schedule of Benefits, subject to all applicable conditions and exclusions, if the Covered Person suffers a covered loss resulting, directly and independently of all other causes, from a Covered Accident that occurs during a Carjacking of a Private Passenger Automobile that the Covered Person was operating, getting into or out of, or riding in as a passenger. Verification of the Carjacking must be made part of an official police report within 24 hours of the Carjacking, or as soon as reasonably possible, or be certified in writing by the investigating officer(s) within 24 hours or as soon as reasonably possible. For purposes of this benefit, Carjacking means a person other than the Covered Person taking unlawful possession of a private passenger automobile by means of force or threats against the person(s) then rightfully occupying it. Rehabilitative Therapy Benefits If you suffer an injury which results in a dismemberment loss covered under the Business Travel Accident Insurance, the Insurance will pay an additional 20% of your full benefit amount for Rehabilitative physical therapy that is prescribed by the attending Physician or surgeon, subject to a maximum of $20,000. The Business Travel Accident Insurance will also pay a benefit equal to 10% of your basic Business Travel Accident benefit, subject to a maximum of $25,000. For purposes of these benefits, Rehabilitation means medical services, supplies, or treatment or hospital confinement (or part of a hospital confinement) that satisfies all of the following conditions: Are essential for physical rehabilitation required due to your covered accident. Meet generally accepted standards of medical practice. Are performed under the care, supervision or order of a physician. Prepare you to return to your previous or any other occupation. In addition, you must require Rehabilitation within two years after the date of your covered accident. Coma Benefit If within 365 days from the date of a Covered Accident you are in a coma for at least 31 consecutive days, Business Travel Accident Insurance, if applicable, will pay you a monthly benefit up to a maximum of 11 months. This monthly benefit is 110

115 equal to 1% of your Business Travel Accident death benefit amount (less the amount of any other benefit paid under the Plan for loss arising out of the same accident). After 11 months of payment, the Plan will pay you 100% of the remaining Business Travel Accident death benefit amount in the 12th month. The benefits described above will be payable for each month that you are in a continuous coma up to a maximum of 11 months. No coma benefit will be payable after the comatose condition ends, whether by death, recovery or any change of condition. Seat Belt/Airbag Benefit If you die as a result of a motor vehicle accident while operating or riding as a passenger in any private passenger motor vehicle designed for use primarily on public roads and at the time of the accident you were wearing a seat belt or lap shoulder restraint, your beneficiary may be entitled to a benefit amount under the Business Travel Accident Insurance. If your Business Travel Accident Insurance applies to your accident, your beneficiary will be entitled to the following: Seatbelt Benefit 10% of the full amount of your Business Travel Accident benefit up to a maximum of $25,000 Airbag Benefit 5% of the full Business Travel Accident benefit up to a maximum of $10,000 Default Benefit $1,000 Verification of the use of a seat belt or lap shoulder restraint and that the airbag properly inflated upon impact at the time of loss is required in the official report of the accident through certification by the investigating officers or by other reasonable proof determined by the insurer. Also, in the case of a child, seatbelt means a child restraint as required by state law and approved by the National Highway Traffic Safety Administration, secured and used as recommended by the manufacturer. A seat belt or airbag benefit is not payable for any death caused by, contributed to, or resulting from a motor vehicle accident in which the operator of the vehicle is intoxicated or under the influence of drugs or narcotics, unless prescribed by a Physician for a medical condition other than drug addiction. The determination as to whether the operator of a vehicle was intoxicated shall be made in accordance with the laws of the state in which the motor vehicle accident occurred. Exposure and Disappearance Coverage If you die or experience a physical loss which results directly and independently of all other causes* from unavoidable exposure to the elements following a covered accident, your Business Travel Accident benefits, if applicable, will be paid according to the same death benefit and Dismemberment and Loss of Use Schedules as apply to your Business Travel Accident Insurance. *If you disappear and are not found within one year from the date of the wrecking, sinking or disappearance of a conveyance in which you were riding in the course of a trip which would be covered under the Business Travel Accident Insurance, it will be presumed that your death resulted directly and independently of all other causes. Felonious Assault and Violent Crime Coverage You will be entitled to the Business Travel Accident benefit, subject to all applicable conditions and exclusions of the Business Travel Accident Insurance, if you die or suffer a covered loss resulting directly and independently of all other causes, from a covered accident that occurs during a violent crime or felonious assault on the business or premises of the Employer. A police report on the felonious assault or violent crime must be proved in order to receive the benefit. To qualify for the benefit, the covered accident must occur during any of the following: Actual or attempted robbery, holdup or kidnapping. Any other type of intentional assault that is a crime classified as a felony by the law in the state where the felony occurs. The benefit will not be paid for any covered loss incurred during any: Violent crime or felonious assault committed by you. 111

116 Felonious assault or violent crime committed upon you by a fellow Employee, Family Member or member of your household. Of the other exclusions listed in the Accident Insurance Exclusions section listed above. Family Member means your parent, step-parent, Spouse or former Spouse, children, parents-in-law or siblings-in-law, aunts, uncles, cousins, grandparents, grandchildren and stepchildren. Fellow Employee means a current Employee of the Employer, as well as a former Employee who was terminated within 45 days of the violent crime/felonious assault. Bereavement and Trauma Counseling Benefit Your Business Travel Accident Insurance will pay a benefit for counseling when you or a Family Member requires bereavement and/or trauma counseling if you suffered a covered loss resulting directly and independently of all other causes from a covered accident. The benefit is equal to $50 per counseling session, up to 10 sessions and up to a maximum of $500 per covered accident. To qualify, the counseling must meet all of the following conditions: The covered counseling expenses must be incurred within one year from the date of the covered accident that caused the covered loss. The expense is for covered counseling for you or one of your Family Members. The counseling is provided under the care, supervision or order of a Physician. You would have been required to pay for the counseling charge if you did not have insurance. Family Member means your Spouse, brother-in-law, sister-in-law, son-in-law, daughter-in-law, mother-in-law, father-in-law, parent or step-parent, brother or sister (including step-brother or step-sister), or your children (including legally adopted children or step-children). Home Alteration and Vehicle Modification Benefit Your Business Travel Accident Insurance will pay a benefit for an adaptive device or alteration of your home and/or modification of your vehicle in the amount of 10% of your full Business Travel Accident Amount up to a maximum of $25,000 if you suffer a covered loss resulting, independently and directly from other causes, from a Covered Accident. This benefit will be payable if all of the following conditions are met: Before the Covered Accident, you did not require use of any adaptive device or adaptations of your home or vehicle. As a direct result of your covered loss from the Covered Accident, you require the adaptive device or adaptation of your home or vehicle to maintain an independent lifestyle. You require the home alteration or vehicle modification within one year of the date of the Covered Accident. EXCLUSIONS The Business Travel Accident Insurance does not cover losses from the following: Intentionally self-inflicted injury, suicide or any attempt thereat while sane or insane. Commission or attempt to commit a felony or an assault. Commission of or active participation in a riot or insurrection. Bungee jumping, parachuting, skydiving, parasailing, hang-gliding. Declared or undeclared war or act of war. Flight in, boarding or alighting from an aircraft or any craft designed to fly above the Earth s surface: except as a passenger on a regularly scheduled commercial airline. being flown by you or in which you are a member of the crew. being used for: o crop dusting, spraying or seeding, giving and receiving flying instruction, firefighting, sky writing, sky diving or hang-gliding, pipeline or power line inspection, aerial photography or exploration, racing, endurance tests, stunt or acrobatic flying; or o any operation that requires a special permit from the FAA, even if it is granted (this does not apply if the permit is required only because of the territory flown over or landed on). designed for flight above or beyond the earth s atmosphere. 112

117 in an ultra-light or glider. being used for the purpose of parachuting or skydiving. being used by any military authority, except an aircraft used by the Air Mobility Command or its foreign equivalent. Sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof, including exposure, whether or not accidental, to viral, bacterial or chemical agents except for any bacterial infection resulting from an accidental external cut or wound or accidental ingestion of contaminated food. Travel in any aircraft owned, leased or controlled by McDonald s or any of its subsidiaries or affiliates. An aircraft will be deemed to be controlled by McDonald s if the aircraft may be used as McDonald s wishes for more than 10 straight days, or more than 15 days in any year. A covered accident that occurs while engaged in the activities of active duty service in the military, navy or air force of any country or intentional organization. Covered accidents that occur while engaged in Reserve or National Guard training are not excluded until training extends beyond 31 days. In addition, benefits will not be paid for services or treatment rendered by you, a Physician, Nurse or any other person who is: employed or retained by McDonald s. providing homeopathic, aroma-therapeutic or herbal therapeutic services. living in your household. you or your spouse s parent, sibling, Spouse or child. Travel while you are on vacation. Travel during a Personal Deviation of greater than 72 hours. Driving any vehicle for pay or hire. Any losses occurring while you are performing your job duties during work hours in a residential area, which are specified in a written telecommuting agreement between you and McDonald s. 113

118 APPLYING FOR SURVIVOR BENEFITS Naming Your Beneficiary It's important to name a beneficiary who will receive your benefits under the Basic and Optional Life, AD&D and Business Travel Accident Insurance. To do so, complete the beneficiary designation form available from the McDonald s Service Center. If you don't name a beneficiary, your benefits under the Basic and Optional Life Insurance will automatically be paid to your estate. If there is no estate, to the extent permitted by law, your benefits may be paid to your relatives who survive you in the following order: 1. First to your Spouse or Domestic Partner; if none, then 2. Next to your child or children, in equal shares; if none, then 3. Next to your parent(s), in equal shares; if none, then 4. Next to your sibling(s), in equal shares. NOTE: For AD&D and Business Travel Accident Insurance, the order of payment is the same as above, except that the estate is paid last. You may change your beneficiary at any time by filling out a new form. Be sure you keep your beneficiary designations up to date. You will automatically be the beneficiary for Dependent Basic Life and Dependent Optional Life benefits. The benefits will be paid to you if you survive the Dependent. In any other instance the benefits will be paid to the Dependent s estate. If there is no estate, then to the extent permitted by law, Aetna may instead pay that amount, divided into equal shares, to each member of the first class in the order listed below in which there is a person who is related to that Dependent and who survives the Dependent: 1. Spouse/Domestic Partner 2. Children 3. Parent 4. Brother and sister When to File a Claim We hope that you and your beneficiary won t need to make a life or accident claim. Before you or your beneficiary can receive insurance benefits, a claim form will have to be completed and returned to the McDonald s Service Center. It is important to file claims as soon as the death certificate is available, or in the case of loss of limb or paralysis, as soon as possible after the injury occurs. If making a claim is necessary, you must give notice of your loss to the McDonald s Service Center within 31 days after the date of your loss or as soon as reasonably possible thereafter. Also, you must send proof of your loss to the McDonald s Service Center as soon as reasonably possible after the date of your loss. It is important to note, however, that in any event Aetna must receive proof of your AD&D loss and Cigna must receive proof of your Business Travel Accident loss within one year after you give notice, unless you are incapacitated. If you have questions about filing a claim, contact the McDonald s Service Center at (877) If a Claim Is Denied Once you complete your application for a benefit, you normally will receive a response within 90 days or notice of a delay of up to an additional 90 days including the reason for delay and date the formal notice can be expected. If a claim is denied, either totally or partially, you or your beneficiary will receive a written notice within the first 90 days. The notice will explain the reason for the denial, refer to the specific Plan provision or provisions on which the denial is based, describe what additional information, if any, is necessary, describe how claims are reviewed, and explain the steps for an appeal. If you or your beneficiary disagree with a claim denial, you, your beneficiary, or an authorized administrator may make a written request for appeal to Aetna for the Life and AD&D Insurance and to Cigna for Business Travel Accident Insurance to the appropriate address indicated below. The request must be made within 60 days after receiving notice that the claim is 114

119 denied. If you do not file a written request for review of a claim denial within that 60-day period, you will have no further right to review and no right to bring action in any court, and the denial of the claim shall be final and binding. Within 60 days after a written request for a review is received, you or your beneficiary will receive a written notice of the final decision or of the reason for the delay in reaching a final decision if special circumstances require an extension of time of up to an additional 60 days. The decision on review will be final and binding on all persons for all purposes. If you have questions on the appeal process, contact either Aetna or Cigna directly. File your appeal for Life or AD&D Insurance benefits with Aetna at the following address: Standard Mail: Aetna Life Insurance Company P.O. Box Lexington, KY Overnight Mail: ACS Attn: Life Claims/Aetna Group SBU 101 Yorkshire Boulevard Lexington, KY File your appeal for Business Travel Accident benefits with Cigna at the following address: P.O. Box Pittsburgh, PA (800) (Toll Free) In carrying out their respective responsibilities under the Plan, the Plan Administrator shall determine eligibility for coverage under the Plan and Aetna or Cigna, as applicable, shall determine all other issues related to entitlement to benefits under the Plan. In doing so, the Plan Administrator, Aetna or Cigna, as applicable, shall have the discretionary authority to interpret the terms of the Plan and to determine the eligibility for and entitlement to Plan benefits in accordance with the foregoing sentence and the terms of the Plan. Any interpretation or determination made pursuant to such discretionary authority shall be given full force and effect, unless it can be shown that the interpretation or determination was arbitrary or capricious. Payment of Benefits Your Basic and Optional Term Life, AD&D and Business Travel Accident and all Dependent coverages are payable only in a lump sum. Gift Assignments Ownership of all of your Employee life insurance coverages may be irrevocably transferable by gift assignment to a trust or an individual. This means you can transfer your ownership rights of the insurance to someone else or to a trust. Once you assign your benefits, all policy rights, title, interest and incident of ownership, both present and future, are transferred to the new owner, including the right to change your beneficiary. The assignment will become effective when it is received and recorded by McDonald's. You cannot assign your Dependent coverages. Accelerated Benefit Option for Terminal Illness If you become Terminally Ill and have coverage of at least $6,250 under the Employee Basic or Optional Life Insurance, you may request a payout of up to 75% of that life insurance benefit, to a maximum of $1,000,000 for Basic Life and $1,000,000 for Optional Life prior to death. To receive this accelerated benefit option, you must submit proof of Terminal Illness that is satisfactory to Aetna. Aetna may request that you be examined by a Physician of their choice, at their expense. This same benefit is available for your Spouse or Domestic Partner if he or she has at least $6,250 of coverage under Optional Dependent Life Insurance, becomes Terminally Ill and submits proof of Terminal Illness as described above. 115

120 Payment of the accelerated benefit will reduce accordingly the amount of life insurance payable upon death and the amount available for you to convert to a personal policy of life insurance. If you have questions, contact the McDonald s Service Center. If your life insurance benefit is scheduled to reduce within 24 months from the date Aetna certifies your eligibility for this option, Aetna will, for the purpose of determining the amount of your accelerated benefit, deem the amount of your life insurance benefit to already have been reduced on such certification date. Accelerated Benefits are not payable if life benefits are assigned. For this purpose, Terminal Illness means that due to Injury or Sickness, you (or, if applicable, your Spouse or Domestic Partner) are expected to die within 24 months. Legal Actions No legal actions may be brought to recover benefits for AD&D or Business Travel Accident Insurance less than 60 days after written or authorized electronic proof of loss has been furnished as required by Aetna or Cigna. No such action will be brought more than 3 years after the time such written proof of loss must be furnished. 116

121 WHEN YOUR SURVIVOR INSURANCE ENDS When you stop being an active Employee or your Dependent loses coverage, contact the McDonald s Service Center about the options you have to continue coverage. It is your responsibility to find out about your options within 31 days of the coverage ending date. For Employees, coverage ends on the earliest of: The last day of the month in which your employment ends. The last day of the month in which you stop being an eligible Employee. The last day of the month in which you retire. When you stop making contributions. When the Plan stops or a particular insurance coverage is eliminated. When the Plan is amended to change your coverage. For your Dependent(s), coverage ends on the earliest of: The date your insurance stops. (Insurance for all of your Dependents stops when your insurance stops.) When you stop making contributions. The last day of the month in which you die. The Dependent becomes covered as an Employee under the survivor benefit plans. The last day of the month in which the Dependent stops being an eligible Dependent. The Plan is amended to change your Dependent's coverage. A mentally or physically handicapped child s healthcare coverage will not stop due to age. It will continue as long as your Dependent child s coverage continues and the child continues to meet the following conditions: The child is handicapped. The child is not capable of self-support. The child depends mainly on you or other care providers for lifetime care and supervision. You must give proof that the child meets these conditions when requested. Proof will not be asked for more than once a year. However, you may not add coverage for a handicapped child who has stopped being an eligible Dependent. 117

122 SITUATIONS THAT MAY AFFECT YOUR SURVIVOR INSURANCE BENEFITS It is important to remember the following: If you enroll for Optional Term Life Insurance and you stop paying your premiums, coverage on that insurance (as well as on the Optional Dependent Life Insurance and Optional AD&D Insurance that goes along with it) will stop. Some accidents are not covered under the Employee Basic and Optional AD&D and the Business Travel Accident Insurance. See the Exclusions sections. If You Are On Leave of Absence If you are on an approved medical or family leave of absence, your Basic Life and AD&D Insurance coverage will continue automatically and you can choose to continue your Optional Insurance coverage. If you choose not to continue your Optional Insurance coverage while on leave, and wish to re-enroll upon return from leave, you will be required to show evidence of insurability and be approved for coverage by Aetna. If you are on personal or military leave (or a leave of absence that has not been approved) of 31 days or more, your Basic Life and AD&D Insurance coverage and Optional Insurance coverage will end as of the end of the month for which your last premium was paid. However, you have the option of converting your Basic Life, Optional Term Life Insurance and Dependent Life Insurance to an individual policy within 31 days of the date your coverage ends. If you choose to not continue your Optional Insurance coverage while on leave, and wish to re-enroll upon return from leave, you will be required to show evidence of insurability and be approved for coverage by Aetna. You cannot convert your Basic or Optional AD&D Insurance. If You Are On Long Term Disability Employee Basic Life Insurance is continued for you by McDonald s while you are on Long Term Disability (LTD) at no cost to you and you can choose to continue your Optional Life Insurance at your own cost. This coverage will end when you reach age 65 or the disability ceases, whichever occurs first. You have the option of converting your Optional Term Life Insurance plus Basic and Optional Dependent Life Insurance to an individual policy within 31 days of the date your coverage ends at your own cost. When You Reach Age 65 When you reach age 65 and remain eligible, your Employee Basic Life Insurance and Optional Term Life Insurance, in addition to your AD&D Insurance benefit (both Basic and Optional), automatically are reduced to 65% of the original amount of coverage. This reduction is effective on the January 1 st following the date you reach age 65. Coverage continues at this reduced level as long as you continue to be eligible. Your premiums for optional coverage will be adjusted to reflect your reduced coverage. Your Business Travel Accident Insurance is not reduced as long as you continue to be eligible. 118

123 CONVERTING BASIC, OPTIONAL TERM & DEPENDENT LIFE COVERAGES If you leave McDonald's or change your status so you are no longer an eligible Employee, you will have the opportunity to convert your Employee Basic Life Insurance and Optional Life Insurance, as well as Basic and Optional Dependent Life Insurance coverage to an individual policy. It is your responsibility to apply for conversion. You will receive a conversion notice within two weeks after your Basic and Optional Life Insurance ends. If you do not receive a conversion notice within two weeks after your Basic or Optional Life Insurance ends, contact McDonald s Service Center at (877) immediately to request a conversion form. To apply for conversion, contact Aetna at (877) for information on how to obtain an individual policy. You must elect conversion coverage within 31 days after your insurance ends or you forfeit your right to conversion. You may choose any of the policies offered by Aetna for up to the amount of your prior coverage. If you have been a Plan participant for at least five years and your coverage stops due to termination of the Plan or elimination of Basic and Optional Life Insurance or the elimination of your eligible class, you will also have the opportunity to convert your coverage, but the new policy will be the lesser of: $10,000 or The amount of your prior coverage less the amount of any group life insurance that you become eligible for and takes effect during the 31-day conversion period. Any other "group life insurance" refers to policies issued or reinstated by Aetna or another insurance carrier. Again, you must elect conversion coverage within 31 days after your insurance ends. The policy can be any one of the group conversion policies offered by Aetna. However, the policy will not have disability benefits or other extra benefits. Whether or not you convert your insurance, if you die within 31 days after the date coverage ends, your beneficiary will receive the life insurance available at the time coverage ended. Your Dependents may also convert their coverage to individual policies. The same rules apply. In addition, your Dependents may convert their coverage if you die or the Dependent no longer qualifies as an eligible Dependent. 119

124 LONG TERM DISABILITY The Group Insurance Plan also provides Long Term Disability Insurance. If you are covered under the Long Term Disability (LTD) benefit, the LTD Insurance will replace part of your salary while you are disabled because of an extended illness or injury. MetLife is the insurer and Claims Administrator of the LTD Insurance. ELIGIBILITY Eligible Employees You are an Eligible Employee if you are a Full-Time or Part-Time Staff, Restaurant General Manager, Department Manager, Certified Swing Manager or Primary Maintenance Employee on the U.S. payroll of McDonald s or another Employer. Full- Time means you are regularly scheduled to work at least 35 hours per week. Part-Time means you are regularly scheduled and working at least 20 hours per week. Enrollment Process McDonald's provides LTD coverage to eligible employees at no cost. You do not have to enroll for LTD coverage. Once you become an Eligible Employee and complete the waiting period described below, you are automatically enrolled in LTD coverage. When LTD Coverage Begins Your LTD coverage starts on the first day of the month after you complete one month of service in the eligible position (4 consecutive weeks of service if you reside in Hawaii or Guam), provided you are Actively at Work (see Glossary) on that date. If you are not Actively at Work on that date, the coverage will take effect on the day you resume Active Work. QUALIFYING FOR LTD BENEFITS You must complete a 180-day elimination period from your first day of being Disabled before LTD benefits become available. Disabled or Disability means: Due to a Sickness or as direct result of an Injury*, you are receiving Appropriate Care and Treatment from a Physician** for the condition that caused the Disability, not from other causes; MetLife determines that you are Disabled and eligible for LTD benefits; You are unable to earn: During the Elimination Period and the next 24 months of Sickness or accidental injury, more than 80% of Your Predisability Earnings at Your Own Occupation from any employer in Your Local Economy; and After such period, more than 60% of your Predisability Earnings from any employer in your local economy at any gainful occupation for which you are reasonably qualified, taking into account your training, education and experience. Appropriate Care and Treatment means medical care and treatment that is: Given by a Physician whose medical training and clinical specialty are appropriate for treating your Disability; Consistent in type, frequency and duration of treatment with relevant guidelines of national medical research, health care coverage organizations and governmental agencies; Consistent with a Physician s diagnosis of your Disability; and Intended to maximize your medical and functional improvement. *For purposes of determining if your Disability is the result of an Injury, the Disability must have occurred within 180 days of the Injury and resulted from such Injury independent of other causes. 120

125 **For purposes of the Plan, your Physician cannot be your Spouse or any member of your immediate family (including your or your Spouse s parents, your children, siblings, grandparents or grandchildren.) SCHEDULE OF BENEFITS Monthly Basic LTD Benefit The LTD Insurance pays 60% of the first $41,667 of your monthly Predisability Earnings, which means your monthly gross wages or salary not including bonuses, overtime, stock or stock options awards, contributions by McDonald s to any deferred compensation arrangement and other pay you may receive from McDonald's. For Restaurant Department Managers or Manager Trainees, Predisability Earnings will mean your hourly rate of pay multiplied by 2,470 hours per year divided by 12. Your benefit amount is reduced by certain income from other sources. See Income Which Will Reduce Your LTD Benefit below. Maximum and Minimum Benefit The maximum monthly benefit is $25,000. The minimum monthly benefit is 10% of the monthly benefit before reductions for other income, or $100, whichever is greater. The minimum monthly benefit will not apply if you are in an overpayment situation or are receiving income from employment under the Work Incentive provision. Maximum Benefit Period The Maximum Benefit Period to receive LTD is the later of: Your normal retirement age as defined by the Social Security Administration on the date your Disability starts or According the following table: Increases in LTD Coverage Age on Date of Disability Benefit Period Less than 60 To age months months months months months months months months months 69 and over 12 months Your LTD coverage will automatically increase on the same day as any promotion or salary increase takes effect, if you are Actively at Work on that date. If you are not Actively at Work on that date, the insurance increase will take effect on the day you resume Active Work. Changes will only apply to Disabilities beginning on or after the date of the change. Decreases in LTD Coverage Your LTD coverage will automatically decrease on the same day as any demotion or salary decrease takes effect. Changes will only apply to Disabilities beginning on or after the date of the change. 121

126 WHEN YOUR LTD COVERAGE ENDS Your LTD coverage ends on the earliest of: The date the group policy ends. The date eligibility ends for your class. The last day of the month in which you stop being an Eligible Employee, if you are not Disabled on that date. The date your coverage ends while on a leave of absence (see below). The last day of the month in which you retire. The last day of the month in which your employment ends. IF YOU ARE ON A LEAVE OF ABSENCE Unpaid Medical Leave If you go on an approved unpaid medical leave, your LTD coverage will be continued for the period of leave, up to 30 months and will end when your unpaid medical leave ends. Family and Medical Leave (FMLA) If you go on an approved FMLA leave, your LTD coverage will be continued for up to 12 weeks and will end at the end of the third month of your FMLA leave. Unpaid Personal and Military Leave If you go on an approved unpaid personal or military leave, your LTD coverage ceases. REINSTATEMENT OF DISABILITY INCOME INSURANCE If your LTD coverage ends because you are no longer an Eligible Employee or your employment ended, and you become eligible again within 12 months of the date your coverage ended, your LTD coverage may be reinstated and you will not have to complete a new waiting period or provide evidence of insurability. The limitation for pre-existing conditions (see Pre- Existing Conditions below) will be applied as if your insurance had been in effect with no interruption. The 12-month period may be longer if your coverage ends due to certain approved military leaves of absence. PAYMENT OF BENEFITS If you become Disabled while covered, you must provide proof of Disability to MetLife. The claim will be reviewed by MetLife and if approved, MetLife will pay the monthly benefit up to the Maximum Benefit Period as indicated in Maximum Benefit Period above. MetLife may periodically request proof that you continue to be Disabled, which may include physical exams, in-home interviews or functional capability exams. While you are Disabled, your monthly benefit will not be affected if your insurance ends or the group policy is amended to change benefits for your class. If approved, you will be entitled to your LTD benefit as of the day after you completed your elimination period. Your first LTD benefit will begin to be paid one month after your elimination period is completed. Your LTD benefit will be paid monthly as long as you continue to be Disabled. Your payment will be prorated for any partial month of Disability. Recovery From a Disability If you return to Active Work, you will be considered recovered from your Disability. Returning Before Completing the Elimination Period If you return to Active Work before completing your elimination period for a period of 90 days or less, and then become Disabled again due to the same or related Sickness or Injury, you will not have to complete a new elimination period. Those days will be counted toward the completion of your elimination period. 122

127 If you return to Active Work for a period of more than 90 days, and then become Disabled again, you will have to complete a new elimination period. Returning After the Elimination Period If, after completing your elimination period, you return to Active Work for a period of 180 days or less, and then become Disabled again due to the same or related Sickness or Injury, you will not have to complete a new elimination period. Your Disability will be treated as part of your original Disability and the same terms and conditions of your original Disability, including your Predisability Earnings, will apply. If you return to work for a period of more than 180 days and then become Disabled again, you will have to complete a new elimination period. Rehabilitation and Other Incentives Rehabilitation Incentive If you participate in a Rehabilitation Program (see Glossary), your monthly benefit will be increased by 10%, and the incentive will be applied before your monthly benefit is reduced by any other income. Work Incentive If you are able to work while you are Disabled, your monthly benefit will be adjusted as follows: Your monthly benefit will be increased by any rehabilitation incentive received. Your monthly benefit will be reduced by other income defined in the Income Which Will Reduce Your LTD Benefit section below. Your adjusted monthly benefit will not be reduced by the amount you earn from working, except to the extent that the adjusted benefit and the amount you earn from working exceeds 100% of your Predisability Earnings. In addition, the minimum monthly benefit will not apply. The work incentive is limited. After the first 24 months following your elimination period, your monthly benefit will be reduced by 50% of the amount you earn from working while Disabled. Family Care Incentive If you participate in a Rehabilitation Program or work while you are Disabled, you can be reimbursed for up to $400 in monthly expenses you incur for: Care for your or your Spouse s or Domestic Partner s child, legally adopted child or child for whom you or your Spouse or Domestic Partner is the legal guardian and who lives with you as part of your household, is dependent on you for support and is under the age of 13. Care must be provided by a licensed child care provider who is not a member of your immediate family or living in your residence. Care for your family member who is living with you as part of your household, is chiefly dependent on you for support and incapable of independent living, regardless of age, due to mental or physical handicap as defined by applicable law. Again, care must not be provided by a member of your immediate family. You will receive the family care incentive on a monthly basis, not to exceed 24 monthly benefit payments. Benefit payments cannot be made beyond the Maximum Benefit Period. You must submit proof to MetLife of your family care expenses. You are not eligible for the incentive if your family care expenses are reimbursed from any other source. Moving Expense Incentive If you participate in a Rehabilitation Program and move to a new residence recommended as part of the program, you may be reimbursed for moving expenses. Reimbursements must be approved by MetLife in advance, and you must supply proof of expenses incurred. Expenses for services provided by a member of your immediate family or someone who is living in your residence will not be reimbursed. 123

128 LIMITATIONS ON YOUR LTD BENEFIT Income Which Will Reduce Your LTD Benefit Your LTD benefit will be reduced by the amount of Other Income you receive. Other Income includes: Disability or retirement benefits which you, your Spouse or your child(ren) receive under the Federal Social Security Act, Railroad Retirement Act, any state or public employee retirement or disability plan, and any pension or disability plan of any other nation. Disability or retirement income received under your Employer s retirement plan (not including profit sharing or 401(k) plans, nonqualified plans of deferred compensation, IRAs and stock ownership plans). Disability income received under a group insurance policy, a government compulsory benefit plan or program, a selffunded plan, any sick pay, vacation pay or other salary continuation your Employer pays to you, workers compensation or similar law, occupational disease laws, laws providing maritime maintenance and cure and any unemployment insurance law or program. Income that you receive from working while Disabled to the extent that such income reduces your monthly benefit as described in the Rehabilitation Incentive section above. Recovery amounts you receive for loss of income as a result of claims against a third party. Amounts you receive under a no fault law for loss of income. How Your Social Security Benefits Affect Your LTD Benefit You are expected to apply for Social Security disability benefits if there is a reasonable basis to do so. If you do not show proof of having applied for Social Security disability benefits within 6 months following the date you became Disabled, an estimate of your Social Security disability benefits will be applied to reduce your LTD benefit. However, if you do show proof of having applied for Social Security disability benefits and you proceed through the Social Security application process, no Social Security reduction will be applied during your first 24 months of LTD benefits. If after 24 months of receiving LTD benefits you still have not been approved for benefits and have not shown proof that the Social Security application process has been exhausted and all levels of appeal have been completed, the Social Security estimate will be applied to reduce your LTD benefit. Of course, once you actually begin receiving Social Security benefits, your LTD benefit will be reduced by the actual amount of your Social Security disability benefit. Within six months following the date you become Disabled, you must: Send MetLife proof that you have applied for Social Security benefits; Sign a reimbursement agreement that states you ll repay MetLife for any overpayments MetLife may make; and Sign a release that authorizes the Social Security Administration to provide information directly to MetLife concerning your eligibility. Notify MetLife immediately when you receive approval or denial of your claim for Social Security disability benefits. You may be required to repay MetLife for any overpayments. Single Sum Payment If you receive Other Income in the form of a single sum payment, you must submit written proof to MetLife within 10 days after receipt of such payment that includes: The amount of the single sum payment; The amount to be attributed to income replacement; and The time period for which the payment applies. MetLife will adjust the amount of your LTD benefit based on any single sum payment it is aware of, whether or not you submit proof. If an adjustment is made, it will not result in a benefit amount less than the minimum amount, except in the case of overpayment. 124

129 Income Which Will Not Reduce Your Disability Benefit MetLife will not reduce your LTD benefit to less than the minimum benefit, or by: Cost of living adjustments that are paid under any of the above sources of other income. Reasonable attorney fees included in any award or settlement. Group credit insurance. Mortgage disability insurance benefits. Early retirement benefits that have not been taken voluntarily. Veteran s benefits. Individual disability income insurance policies. Benefits received from an accelerated death benefit payment. Amounts rolled over to a tax-qualified plan unless subsequently received by you while you are receiving benefit payments. When LTD Benefit Payments End Your LTD benefit will end on the earliest of: The end of the Maximum Benefit Period. The date specified in the Limited LTD Benefits for Certain Conditions section. The date you are no longer Disabled. The date you die (except for benefits paid as defined in the In the Event of Your Death section). The date you cease or refuse to participate in a required Rehabilitation Program. The date you fail to have a requested physical exam. The date you fail to provide proof of continued Disability. The date you are not under the continuous care of a Physician. While you are Disabled, your benefits will not be affected if your insurance ends or the policy is amended to change the benefits for your class. In the Event of Your Death If you die while you are Disabled and receiving monthly benefits, upon receipt of proof of death a benefit will be paid equal to 3 times the lesser of: The monthly LTD benefit received in the calendar month immediately preceding your death. The monthly LTD benefit received in the calendar month immediately preceding your Terminal Illness (if your benefit was increased due to your Terminal Illness). The monthly LTD benefit you were entitled to receive for the month you die, if you die during the first month that benefits are payable. MetLife will reduce the benefit amount by any overpayment. This benefit will not be paid if you receive a single sum payment in the event of your Terminal Illness. (See below.) In the Event of Your Terminal Illness If you become Terminally Ill while you are Disabled and receiving monthly benefits, the following benefit(s) will be paid upon receipt of proof of Terminal Illness in the form of a signed Physician's certification. MetLife may also request an exam by a Physician of their choice. For this purpose, Terminal Illness or Terminally Ill means that due to injury or sickness you are expected to die within 12 months. Monthly Benefit Increase Your monthly LTD benefit amount will be increased to 100% of your Predisability Earnings for a maximum of 12 consecutive months, beginning with the next payment due following receipt of proof of your Terminal Illness. 125

130 Single Sum Payment In addition to your monthly LTD benefit, you may elect to receive a benefit as a single sum payment. This additional benefit will be equal to 3 times the monthly benefit you receive in the calendar month immediately preceding the month you were diagnosed as Terminally Ill. If you elect the single sum payment, no LTD payments will be made in the event of your death. Pre-Existing Conditions For purposes of your LTD benefit, a pre-existing condition is a Sickness or Injury occurring in the 3 months before your LTD coverage (or an increase in your coverage) takes effect for which you: Received medical treatment, consultation, care or services; Took prescription medication or had medications prescribed; or Had symptoms or conditions that would cause a reasonably prudent person to seek diagnoses or treatment. You will not be entitled to an LTD benefit (or increase in your LTD coverage) for a Disability that results from a pre-existing condition if you have been Actively at Work for less than 12 months after your LTD coverage (or increase in your LTD coverage) is effective. Limited LTD Benefits for Certain Conditions If you are Disabled due to alcohol, drug or substance addiction, the Plan will only cover one such period of Disability within your lifetime and will require that you participate in a recovery program recommended by your Physician. In addition, your payments will end after 24 months, the date you end or refuse to participate in a recovery program, or the date you complete a recovery program, whichever is earliest. If you are Disabled due to one or more of the following conditions, your LTD benefit payments will end after 24 months or the Maximum Benefit Period, whichever is less. This limit applies to your Disability due to: Mental or nervous disorders or diseases (except for schizophrenia, dementia or organic brain disease); Neuromuscular, musculoskeletal or soft tissue disorder, including, but not limited to, any disease or disorder of the spine or extremities and their surrounding soft tissue (except for seropositive arthritis, spinal tumors, malignancy or vascular malformations, radiculopathies, myelopathies, traumatic spinal cord necrosis, or musculopathies), unless the Disability has objective evidence of seropositive arthritis, spinal tumors, malignancies or vascular malformations, radiculopathies; myelopathies, traumatic spinal cord necrosis, myopathies; or Chronic fatigue syndrome and related conditions. Exclusions The LTD Insurance will not pay LTD benefits for any Disability caused or contributed to by war or acts of war (whether declared or undeclared), your active participation in a riot, intentionally self-inflicted injuries, attempted suicide or commission or attempt to commit a felony. APPLYING FOR BENEFITS Filing a Claim You must apply for benefits by submitting a claim form and proof of your condition. In general, proof means you are able to show the nature and extent of your condition, MetLife s obligation to pay LTD benefits, and your right to receive those benefits. This proof must be provided at your own expense. It's your obligation to obtain an LTD application packet and form, fill it out, have your Physician complete the applicable sections, sign and return it to the McDonald's Service Center. Contact the McDonald s Service Center at (877) for the application packet and form. The notice of claim and required proof should be sent to the McDonald s Service Center within 90 days following the date the elimination period ends. If that is not possible, proof must be submitted no later than 1 year following the date proof was required, except in the absence of legal capacity. If notice of claim or proof is not given within the time limits described above, the delay will not cause a claim to be denied or reduced as long as notice and proof are given as soon as reasonably possible. The following information may be required in your application and/or proof: 126

131 Documentation of the date your Disability began, its cause, its prognosis and continuity of your Disability. Your application for other income, Social Security disability benefits, workers' compensation benefits or benefits under a similar law. Written authorization for MetLife to obtain and release medical, employment, financial and other information MetLife may reasonably require to determine eligibility. Medical information including x-rays, photocopies of medical records, histories, physical, mental and diagnostic exams and treatment notes. Names and addresses of Physicians, other medical practitioners, Hospitals and other medical facilities which have provided diagnoses, treatment or consultation. Names and addresses of Pharmacies which have filled prescriptions within the last 3 years. Legal action on a claim may only be brought against MetLife during the period beginning 60 days after the date proof is filed and ends three years after the date proof is required. Initial Determination After you submit a claim, MetLife will review your claim and notify you of its decision to approve or deny your claim within 45 days from the date you submit a claim and include all required information. In some cases, MetLife may require an extension. MetLife may have up to two 30-day extensions to make its determination. You'll be notified of any extension (and the reason for the extension) before the initial 45-day period ends or prior to the 30-day extension period. If an extension is needed because you did not submit sufficient information, the time between the date MetLife requests additional information and the time MetLife receives the information does not count toward MetLife's time period for responding to your claim. You will have 45 days to supply requested information from the date you receive the notice for additional information. If your claim is denied, in whole or in part, the notification will state the reason why your claim was denied and refer to the specific Plan provision(s) on which the denial is based; what information was insufficient (if any); or any internal rule, protocol, guideline or other criterion that was used in making the denial. Appealing the Initial Determination You can appeal a decision made by MetLife to deny your claim. Upon written request, MetLife will provide you with copies of documents, records and other information relevant to your claim free of charge. Your appeal must be sent to the following address within 180 days of receiving MetLife's decision: MetLife Disability P.O. Box Lexington, KY Appeals must be in writing and include: Name of the Employee; Name of the Plan; Reference to the initial decision; An explanation of why you are appealing; and Any written comments, documents, records or other information relating to your claim. After receiving a written request appealing the initial determination, MetLife will conduct a full and fair review of your claim without deference to the initial denial and will take into account all information submitted with your claim. The person who reviews your appeal will not be the same person who initially denied the claim, nor will he or she be a subordinate of that person. If the initial denial was based in whole or in part on a medical judgment, MetLife will consult with an appropriate health care professional who did not consult on the initial determination and who is not the subordinate of any person who was consulted on the initial determination. MetLife will notify you in writing of its final decision no later than 45 days after MetLife s receipt of your written request for review. Under special circumstances MetLife may have up to 45 additional days and will notify you of such an extension before the expiration of the initial 45-day period, stating the reasons for the extension and the date it will make this determination. If an extension is needed because you did not submit sufficient information, the time between the date MetLife requests additional information and the time MetLife receives the information does not count toward MetLife s time period for responding to your claim. You will have 45 days from the date you received the notice for additional information to supply the additional information. 127

132 If your claim is denied on appeal, MetLife will send you a final written decision that states the reason(s) why your appeal was denied, any specific plan provisions on which the denial was based, any information that was insufficient, and any internal rule, protocol, guideline or other criterion that was used in making the decision. In carrying out their respective responsibilities under the Plan, the Plan Administrator shall determine eligibility for coverage under the Plan and MetLife shall determine all other issues related to entitlement to benefits under the Plan. In doing so, the Plan Administrator and MetLife respectively shall have the discretionary authority to interpret the terms of the Plan and to determine the eligibility for and entitlement to Plan benefits in accordance with the foregoing sentence and the terms of the Plan. Any interpretation or determination made pursuant to such discretionary authority shall be given full force and effect, unless it can be shown that the interpretation or determination was arbitrary or capricious. GENERAL PROVISIONS Assignment The rights and benefits are not assignable prior to a claim of benefits, except as required by law. Who Will Be Paid MetLife will make benefit payments to you or your legal representative. Upon your death, MetLife will pay any amount that is or becomes due to your designated beneficiary. If there is no beneficiary, MetLife will pay the following individuals in this order: 1. Your Spouse or Domestic Partner, if alive; 2. Your unmarried child(ren) under age 25, if there is no surviving Spouse or Domestic Partner; or 3. Your estate, if there is no surviving child. If more than one person is eligible, payments will be divided in equal shares. Payment to a minor or incompetent child will be made to that person's guardian. Periodic payments that are owed may be paid to your estate in a single sum. Physical Exams & Autopsy MetLife has the right to ask the insured to be examined by a Physician(s) of MetLife's choice as often as is reasonably necessary, at MetLife's expense. MetLife has the right to make a reasonable request for an autopsy where permitted by law. The reasons for the request will be stated in the request. Overpayments MetLife has the right to recover any amount they determine to be an overpayment, including: If the amount MetLife pays is more than the total of benefits due to you. If payment made by MetLife should have been paid under another group plan. If such an overpayment occurs, you have an obligation to reimburse MetLife, as outlined in the reimbursement agreement you sign when you submit a claim. Recovery of Overpayments MetLife may recover overpayment from you by stopping or reducing future disability benefits, including the minimum benefit, demanding an immediate refund and taking legal action. If the overpayment results from payments that should have been made under another group plan, MetLife may recover these overpayments through the other insurance company, organization or individual. SPECIAL SERVICES Social Security Assistance Program MetLife will help you apply for Social Security disability benefits. Your tax dollars help fund this program, and it is in your 128

133 best interest to apply for any benefits to which you, your Spouse and your children may be entitled. This includes assistance throughout the application process, guidance through the appeal process by Social Security specialists and referral to attorneys who specialize in Social Security law. Early Intervention Program This voluntary program helps provide early identification of those employees who might benefit from vocational analyses and rehabilitation services before they are eligible for Disability benefits. Return to Work Program The Plan is designed to provide clear advantages and financial incentives for returning to work on a full- or part-time basis while still receiving Disability benefits. MetLife's Return to Work Services include vocational analyses, labor market studies, retraining programs, job modifications/accommodations and job seeking skills and job placement assistance. Once you are Disabled, the case manager assigned to you will coordinate all return-to-work services. In many cases, the services of independent vocational rehabilitation specialists may be used. 129

134 HEALTHCARE SPENDING ACCOUNT The Healthcare Spending Account Plan offers a special tax-saving opportunity by allowing you to use pre-tax dollars for certain out-of-pocket medical and dental care expenses for you and your covered Spouse and Dependents as defined in Your Eligible Dependents in the Enrollment and Cost for Medical, Vision Supplement and Dental Plans section of the SPD. Under IRS rules, you cannot use Healthcare Spending Account dollars to pay expenses for your Domestic Partner or his or her children unless they qualify as your dependent(s) under federal tax rules. You should check with your tax advisor regarding the dependent status of your Domestic partner and his or her children. Your pre-tax dollars set aside in your Healthcare Spending Account are not subject to federal income or Social Security taxes and may not be subject to state tax in some states. Since you are able to use pre-tax salary to pay for eligible expenses, your dollars go further. Eligible Employees You are an Eligible Employee if you are a Full-Time or Part-Time Staff, Restaurant General Manager, Department Manager, Certified Swing Manager or Primary Maintenance Employee on the U.S. payroll of McDonald s or another Employer. Full- Time means you are regularly scheduled to work at least 35 hours per week. Part-Time means you are regularly scheduled and working at least 20 hours per week. Enrollment You must enroll in order to get Healthcare Spending Account coverage. You have the opportunity to participate in the Healthcare Spending Account on a Calendar Year basis as long as you are an Eligible Employee and the Healthcare Spending Account Plan is in effect. When you become a benefits-eligible employee, you will receive instructions on how to enroll. McDonald s must receive your completed election for Healthcare Spending Account coverage before the end of your waiting period. Your waiting period is one calendar month of service in the eligible position (4 consecutive weeks of service if you reside in Hawaii or Guam). During the annual enrollment period, you will have an opportunity to enroll for the following year. You must make your annual enrollment election by the due date set by McDonald s, even if you decide not to use the Healthcare Spending Account. At this time, you will decide how much, if any, you want to contribute to your Healthcare Spending Account for the upcoming year. If you do not make an annual enrollment election, your existing election will remain in effect for the next Plan Year. If you transfer to McDonald s from a benefits-eligible position at any other Employer, your service in the benefits-eligible position with that Employer will count towards your waiting period under the Plan. When Does Coverage Start? Your Healthcare Spending Account coverage starts on the first day of the month following the end of your waiting period, assuming you have enrolled prior to that date. You will only be eligible to submit claims for reimbursement of expenses incurred after your coverage starts. If you were employed in a class of Employees that are not Eligible Employees (such as temporary employees) and you become an Eligible Employee, coverage starts on the first day of the month following the date you complete the waiting period in the eligible class (assuming you have enrolled by that date.) Life Event Changes Once you have elected the amount you will contribute to the Healthcare Spending Account, you cannot stop, increase or decrease your deductions during the Plan Year, unless you have one of the following qualifying life event changes: Marriage, divorce, or annulment.* Birth, adoption, or placement for adoption of a Dependent.* Death of your Dependent or your Spouse.* 130

135 Beginning or termination of employment for you, your Spouse or your Dependent.* Change in employment-related eligibility for you, your Spouse or your Dependent under the Healthcare Spending Account or another healthcare spending account.* Change in eligibility status of your Spouse or Dependents under the Healthcare Spending Account or another healthcare spending account.* Strike or lockout involving you, your Spouse or your Dependent.* Beginning or returning from an unpaid leave of absence by you, your Spouse, or your Dependent (subject to the Unpaid Leave rules below). Your Dependent child s coverage under a Qualified Medical Child Support Order. You, your Spouse or your Dependent child s entitlement to Medicare or Medicaid. Your change of election must be consistent with the life event change. Changes marked by an * are allowed only if the life event change causes you, your Spouse or your Dependent child to gain or lose eligibility for coverage under the Plan or another healthcare spending account. If you have a qualified life event change, you must notify McDonald s within 60 days following the date of the event. Your decision to stop, start, increase or decrease the Healthcare Spending Account must be consistent with and on account of the change. Only those expenses incurred for services provided after an account is opened are eligible for reimbursement. The term Dependent for purposes of the Healthcare Spending Account means the dependents that you can claim for tax purposes, as well as children under age 26. Reducing Your Taxes The pre-tax dollars placed in your Healthcare Spending Account are not subject to federal income or social security taxes and will not be reported as income on your annual W-2 form. This may cause a slight reduction in your social security benefits at retirement. The pre-tax dollars also may not be subject to state tax in some states. Contributions To participate in the Healthcare Spending Account, you must annually contribute a minimum of $120 and may contribute a maximum of $2,500. The amount of your pre-tax salary that you elect to contribute your annual contribution amount will be divided in equal amounts, based on your number of pay periods. These contributions will be withdrawn from your paycheck each pay period. The amount you choose to contribute should reflect your best estimate of eligible expenses for the coming Calendar Year. Forfeitures You must use your account balance for a Calendar Year to pay for expenses incurred during that Calendar Year or during a grace period that ends on March 15 th following the end of the Calendar Year. Internal Revenue Service (IRS) regulations require that any funds not used by the end of the grace period for the Calendar Year will be forfeited. You have until May 31 st following the end of the Calendar Year to submit claims for eligible healthcare expenses incurred during that Calendar Year (and the grace period). For this year, your deadlines are: Action Timeframe Begins Timeframe Ends_ Contribute to Spending Account January 1 st of this year or first December 31 st of this year or day you re enrolled in Plan date your Plan participation ends, if sooner Incur Eligible Expenses January 1 st of this year or first March 15 th of next year or date day you re enrolled in Plan your Plan participation ends, if sooner Request Reimbursement for January 1 st of this year or first May 31 st of next year Eligible Expenses day you re enrolled in Plan 131

136 Any forfeited money will be held and applied for the benefit of the participants or to reduce Plan expenses. IRS rules will not allow McDonald s to return your unused funds to you. There cannot be carry-overs of prior year contributions for current or future expenses except for the grace period. Eligible Expenses You can use your Healthcare Spending Account to pay for medical and dental care Deductibles, Copays, Coinsurance and certain medical and dental expenses for you and your Dependents which are not covered under the Medical and Dental Plans. If you incur an eligible expense that exceeds the amount of your current Healthcare Spending Account balance, you can receive the full amount of that expense up to your annual contribution amount. However, you cannot use the Healthcare Spending Account to be reimbursed for expenses incurred by your Domestic Partner or his or her children unless the individual qualifies as your dependent under federal tax rules. Check the list of eligible/ineligible expenses on the PayFlex website at Filing a Claim There are 3 ways to file a claim for your expenses: If you re enrolled in the Gold, Silver or Bronze Plan and/or Dental Plan and do not have other medical/dental insurance coverage in your family, your reimbursement from PayFlex is automatic when you file a claim for medical/dental expenses directly with BCBSIL or obtain prescription drugs through CVS Caremark. Any Deductibles, Coinsurance, Copays and ineligible expenses will be automatically transferred to the Healthcare Spending Account system. If you have Domestic Partner coverage, reimbursement from PayFlex will not be automatic and you will need to submit a claim to PayFlex directly for reimbursement for your own eligible expenses and those of your family members who are your dependents for tax purposes. For submitting claims that are not automatically processed, you must fill out and submit a reimbursement form to PayFlex. Also, if you re enrolled in an HMO/DHMO or have coverage under another plan, first submit your bills to those other carriers. You must then fill out a reimbursement claim form, attach the Explanation of Benefits form (from the other carrier) and send it to PayFlex. The claim form and filing instructions are available at If you do not have Internet access, you can also obtain a claim form by calling the PayFlex Info Line at (800) (available 7:00 a.m. 7:00 p.m. CT, Monday through Friday). Then attach the information required above and mail it to the address indicated on the claim form. Or, you can use PayFlex s Express Claims service, where you fill out the claim form online, print and sign the form and fax your completed form with itemized receipts to PayFlex as directed on the form. You can also upload and submit the form online via the website using the Express Claims instructions. Checks are issued only to the Employee. You can also register through the PayFlex Service Center at to have reimbursements sent directly to your bank account. A statement of your account balance is included with each reimbursement check. See also Applying for Benefits and the Appeals for Medical, Dental, Employee Resource Connection and Healthcare Spending Account Claims sections of the booklet for important information on how your claim is determined and what you should do to appeal a denial of your claim. If a claim payment/reimbursement check sent to you from PayFlex remains uncashed for one year from the date of issue, PayFlex will return the uncashed check amounts to the Plan. You will forfeit those uncashed check amounts within a reasonable time after they are returned to the Plan, and no checks will be reissued to you with respect to those claims. Any such forfeited amounts will be used to pay administrative expenses, including experience loss, under the Plan. Any excess forfeitures will be retained by McDonald s. PayFlex Service Center You can use the PayFlex website at to check your Healthcare Spending Account balance, obtain claim forms and instructions, perform transactions, obtain a direct deposit form to have reimbursements sent directly to your bank account, and more. You will need to register as a user before you can access certain information and features. 132

137 Some Healthcare Spending Account Guidelines The Healthcare Spending Account takes advantage of certain favorable tax laws and therefore must comply with certain additional IRS regulations, as follows: You should remember that once you decide how much to put in the Healthcare Spending Account, you cannot transfer funds between your Healthcare Spending Account and your Dependent Care Spending Account. You cannot change or stop the amount deducted, unless you experience a qualifying life event change. Reimbursement (i) from different healthcare spending accounts for the same expense; (ii) for an expense that s already been fully covered under another benefit plan; (iii) for an expense that is not an eligible expense; or (iv) for the medical expenses of a Dependent who is not your dependent under federal tax rules is not permissible and is against federal law. By filing a Healthcare Spending Account claim, you are stating that those expenses are eligible for reimbursement and are not reimbursed from another source. Special Rules if You Change Your Employment Status If your employment status changes, the following special rules apply: Termination of Employment/Change to an Ineligible Class. If your employment terminates or you are transferred to a class of Employees that is not eligible to participate in the Healthcare Spending Account, all contributions to your Healthcare Spending Account will stop. If you still have money in your Healthcare Spending Account, you can continue to submit claims through May 31 st of the following year to pay for eligible expenses incurred before the end of the month in which your termination or employment change occurred. These provisions also apply if your employment terminates due to Long Term Disability. You may elect to continue to make your Healthcare Spending Account contributions through COBRA through the end of the Plan Year in which your employment change occurred. (See COBRA below.) Short Term Disability/Long Term Disability. Your Healthcare Spending Account contributions will continue while you are receiving short term disability payments. You are not eligible to make Healthcare Spending Account contributions while you are on Long Term Disability. Unpaid Leave (other than FMLA). If you go on unpaid medical or personal or military leave, you can elect to continue making your Healthcare Spending Account contributions through the end of the Plan Year in which your leave began. These contributions must be made on an after-tax basis either in advance before your leave begins or on a monthly basis by check. If payments are not received within 30 days after the leave begins or within 30 days of the due date for a monthly payment, your coverage will be terminated. In that case, you can submit claims for reimbursement only to pay for eligible expenses incurred before your coverage terminated. If you do not arrange to continue your Healthcare Spending Account payments during the leave or fail to make Healthcare Spending Account contributions during the leave and you return from leave in the same Plan Year, you will not be able to participate in the Healthcare Spending Account for the rest of the Plan Year. In that case, you can submit claims for reimbursement only to pay for eligible expenses incurred before the leave. If you return in a later Plan Year, you may make a new election for coverage. The election must be made within 60 days of your return to work. FMLA Leave. See Family and Medical Leave in the Continuation of Coverage While on Leave/Disability section. Qualified Reservist Distribution If you are a member of a reserve unit and are ordered or called to active duty, you may be able to request a Qualified Reservist Distribution (QRD) from your Healthcare Spending Account. A QRD is a distribution of amounts from your Account that are not dependent on whether you incurred medical expenses. You can only request this distribution if you are ordered or called to active duty for a period of more than 180 days or for an indefinite period. The maximum amount that can be paid from your Account through a QRD is the amount that you have contributed to your Account for the Plan Year up to the date of your request for the QRD, minus any reimbursements that have already been paid from your Account (or that are being processed for reimbursement) for that Plan Year. Any claims that you incur after the date of the payment of a QRD from your Account will be paid upon submission the same as any other claim, to the extent that funds are still available for distribution in your Account. A QRD will be subject to income and employment taxes when distributed. 133

138 If you are eligible for and interested in getting a QRD, please contact the McDonald s Service Center for the appropriate form. When Your Participation in the Healthcare Spending Account Ends In addition to the situations for loss of Healthcare Spending Account coverage described above, you will no longer be eligible to participate in the Healthcare Spending Account on the earliest to occur of the following: You stop making contributions. The Plan stops. The Plan is amended so that coverage will end for an entire group of Employees and you are in that group. If your participation ends for one of the above reasons, you can submit claims through May 31 st of the following year for reimbursement to pay for eligible expenses incurred before your participation ended. COBRA If you experience a qualifying event for COBRA coverage (see the Continuation of Coverage Under COBRA section) and have a positive cash balance in your Healthcare Spending Account at that time, you are eligible to elect Healthcare Spending Account COBRA coverage. If you elect Healthcare Spending Account COBRA coverage, you may continue to make contributions pursuant to your election until the end of the Plan Year in which you become eligible for COBRA coverage. Contributions may be continued in the same amount as you were contributing prior to the termination or becoming ineligible. COBRA Healthcare Spending Account contributions are made on an after-tax basis. 134

139 DEPENDENT CARE SPENDING ACCOUNT The McDonald s Corporation Dependent Care Spending Account Plan allows you to set aside money from your paycheck before taxes to pay your eligible Dependent Care expenses, including child care, elder care or care of an incapacitated Spouse or Dependent (including physically or mentally disabled) when those services make it possible for you (and your Spouse) to work. Under IRS rules, you cannot use Dependent Care Spending Account dollars for expenses to care for your Domestic Partner s children or for your incapacitated Domestic Partner unless they qualify as your dependent(s) under federal tax rules. There are two ways to take advantage of tax savings for Dependent Care expenses: You may file for a tax credit annually on your Federal Income Tax 1040 or 1040A form; or You may take advantage of the Dependent Care Spending Account. Eligible Employees You are an Eligible Employee if you are a Full-Time or Part-Time Staff, Restaurant General Manager, Department Manager, Certified Swing Manager or Primary Maintenance Employee on the U.S. payroll of McDonald s or another Employer. Full- Time means you are regularly scheduled to work at least 35 hours per week. Part-Time means you are regularly scheduled and working at least 20 hours per week. Dependents For purposes of the Dependent Care Spending Account, in general a Dependent includes: Your children under age 13 who qualify as your dependent or meet the requirement of a qualifying child under federal tax rules. Your Spouse who is not physically or mentally able to care for himself or herself and who lives with you for more than half the year. Any other family member who (1) is physically or mentally not able to care for himself or herself, (2) lives with you for more than half the year, and (3) you can claim as a dependent for federal income tax purposes (or would be able to claim them except that he or she did not meet the Internal Revenue Code income limit or tax return filing requirements for dependents.) Note: Certain special federal tax rules apply to the Dependent eligibility status of the children of Domestic Partners. You should discuss your family members Dependent status with your tax advisor to make sure their expenses are eligible for reimbursement. Enrollment You must enroll in order to get Dependent Care Spending Account coverage. You have the opportunity to participate in the Dependent Care Spending Account Plan on a Calendar Year basis as long as you are an Eligible Employee and the Dependent Care Spending Account Plan is in effect. When you become a benefits-eligible employee, you will receive instructions on how to enroll. McDonald s must receive your completed election for Dependent Care Spending Account coverage before the end of your waiting period. Your waiting period is one calendar month of service in the eligible position (4 consecutive weeks of service if you reside in Hawaii or Guam). During the annual enrollment period, you will have an opportunity to enroll for the following year. You must make your annual enrollment election by the due date set by McDonald s, even if you decide not to use the Dependent Care Spending Account Plan. At this time, you will decide how much, if any, you want to contribute to your Dependent Care Spending Account for the upcoming year. If you do not make an annual enrollment election, your existing election will remain in effect for the next Plan Year. If you transfer to McDonald s from a benefits-eligible position at any other Employer as defined in the Glossary, your service in the benefits-eligible position with that Employer will count towards your waiting period under the Plan. 135

140 When Does Coverage Start? Your Dependent Care Spending Account coverage starts on the first day of the month following the end of your waiting period, assuming you have enrolled prior to that date. You will only be eligible to submit claims for reimbursement of expenses incurred after your coverage starts. If you were employed in a class of employees that are not Eligible Employees and you become an Eligible Employee, coverage starts on the first day of the month following the date you complete the waiting period in the eligible class, as described above (assuming you have enrolled by that date). Life Event Changes Once you have elected the amount you will contribute to your Dependent Care Spending Account, you cannot stop, increase or decrease your deductions during the Plan Year, unless you have one of the following qualifying life event changes: Marriage, divorce, or annulment.* Birth, adoption, or placement for adoption of your Dependent.* Death of your Dependent or your Spouse.* Beginning or termination of employment for you or your Spouse.* Change in employment-related eligibility for you or your Spouse under the Dependent Care Spending Account Plan or another dependent care plan.* Change in eligibility status of your Dependent under the Dependent Care Spending Account Plan or another dependent care plan.* Strike or lockout involving you or your Spouse.* Beginning or returning from an unpaid leave of absence by you or your Spouse. (See the provisions of Special Rules if You Change Your Employment Status below.)* Change in your Dependent Care provider. Change in the rate charged by your Dependent Care provider (except for certain of your relatives). Change in election under your Spouse s plan if that plan has a different enrollment period. Your change of election must be consistent with the life event change. Changes marked with an * are allowed only if the life event change causes you, your Spouse or your Dependent to gain or lose eligibility for coverage under the Dependent Care Spending Account Plan or another dependent care plan. If you have a qualifying life event change, you must notify McDonald s within 60 days following the date of the event. Your decision to stop, start, increase or decrease the Dependent Care Spending Account must be consistent with and on account of the change. Only those expenses incurred for services provided after an account is opened are eligible for reimbursement. How the Dependent Care Spending Account Works To be eligible for the tax credit or the Dependent Care Spending Account, expenses must be all of the following: Employment related. For an eligible Dependent. Not in excess of the lower of the earned income of the Employee or his or her Spouse. Contributions Under the Dependent Care Spending Account, you may pledge and be reimbursed up to a minimum of $600 and a maximum of $5,000 per Calendar Year for Dependent Care expenses. However, if you are married and you or your Spouse earns less than $5,000 ($2,500 if you are married but file separate tax returns) a year, the most you can contribute is the lower of your two incomes. If your Spouse has no income and is a full-time registered student or is disabled, his or her income is considered to be $250 per month ($3,000 per year) for one Dependent or $500 per month ($6,000 per year) for two or more Dependents. In any event, the maximum family limit is $5,

141 The amount of your pre-tax salary that you elect to contribute your annual contribution amount will be divided in equal amounts, based on your number of pay periods. These contributions will be withdrawn from your paycheck each pay period. The amount you choose to contribute should reflect your best estimate of eligible expenses for the coming Calendar Year. If you utilize the Dependent Care Spending Account, you may be unable to claim part or all of a Dependent Care federal tax credit. You should contact your tax advisor for more details. Forfeitures You must use your account balance for a Calendar Year to pay for expenses incurred during that Calendar Year or during a grace period that ends on March 15 th following the end of that Calendar Year. Internal Revenue Service (IRS) regulations require that any funds not used by the end of the grace period for the Calendar Year will be forfeited. You then have until May 31 st following the end of the Calendar Year to submit claims for eligible expenses incurred during that Calendar Year (and the grace period). For example, you have until March 15 th of next year to incur expenses for this year s Dependent Care dollars. You then have until May 31 st of next year to submit claims for those expenses. According to the IRS rules, any forfeited money will be held and applied for the benefit of the participants and to reduce Plan administrative expenses. If you do not use your total account balance, the money will not be returned. Contributions from prior years cannot be carried over for current or future expenses, except for the grace period. Eligible Expenses Expenses must be necessary so that you can work, or, if you are married, so that you and your spouse can work or your spouse can attend school full-time while you work. Expenses that may be reimbursed under the Dependent Care Spending Account are: Services inside or outside your home by anyone other than your Spouse, someone who is your dependent for income tax purposes, or one of your children under the age of 19. Services in a Dependent Care center or a child care center (if the center cares for more than six children, it must comply with all applicable state and local regulations). Services in a nursery school or preschool. Services by a housekeeper whose responsibilities include, in part, providing care for an eligible Dependent. Expenses for kindergarten or overnight camp cannot be reimbursed under the Dependent Care Spending Account. How Will This Affect The Current Dependent Care Federal Tax Credit? The amount of the expenses claimed under the tax credit may not be more than $3,000 for one Dependent or $6,000 for two or more Dependents. The percentage allowed depends on the Employee's adjusted gross income or the adjusted gross income of the Employee and Spouse if filing jointly. It's your responsibility to decide, under the current tax laws, which tax savings approach is best for you. You should consult your tax advisor to determine which approach best applies to your situation. Additional Considerations To take advantage of either the tax credit or the Dependent Care Spending Account, you will have to provide the name, address and tax identification number or Social Security Number of your Dependent Care provider(s) on your federal tax return. This information is to be reported on Internal Revenue Service Form 2441 if a participant files Form 1040, or Schedule 1 if a participant files 1040A. (Available from the McDonald s Service Center.) Form W-10 may be used by a participant to obtain the above information. This form is to be retained for record purposes and is not to be filed with a taxpayer s tax return. (Available from the McDonald s Service Center.) It s important to remember that under the Dependent Care Spending Account, you will be paying for Dependent Care services with current income, and submitting claims several weeks later. 137

142 Filing a Claim You must submit a claim form to PayFlex to get reimbursement from your Dependent Care Spending Account. You can obtain a reimbursement form from PayFlex. The claim form and filing instructions are available at If you do not have Internet access, you can also obtain a claim form by calling the PayFlex Info Line at (800) (available from 7:00 a.m. 7:00 p.m. CT, Monday through Friday). Then, attach receipts for eligible expenses showing the Dependent Care provider s name and tax identification number (or Social Security number), the name of the Dependent in Dependent Care, the dates of service and the amounts charged for those dates. You should mail the claim form and receipt to the address indicated on the form. Or, you can use PayFlex s Express Claims service, where you fill out the claim form online, print and sign the form and fax your completed form with itemized receipts to PayFlex as directed on the form. You can also upload and submit the form online via the website using the Express Claims instructions. Checks are issued only to the Employee. You can also register through the PayFlex Service Center at to have reimbursements sent directly to your bank account. A statement of your account balance is included with each reimbursement check. If a claim payment/reimbursement check sent to you from PayFlex remains uncashed for one year from the date of issue, PayFlex will return the uncashed check amounts to the Plan. You will forfeit those uncashed check amounts within a reasonable time after the date they are returned to the Plan, and no checks will be reissued to you with respect to those claims. Any such forfeited amounts will be used to pay administrative expenses, including experience loss, under the Plan. Any excess forfeitures will be retained by McDonald s. If a Claim Is Denied Once you complete your application for a benefit, you normally will receive a response within 90 days or notice of a delay including the reason for delay and date the formal notice can be expected. If a claim is denied, either totally or partially, you or your beneficiary will receive a written notice within the first 90 days. The notice will explain the reason for the denial, refer to the specific Plan provision or provisions on which the denial is based, describe what additional information, if any, is necessary, describe how claims are reviewed, and explain the steps for an appeal. If you disagree with a claim denial, you may make a written request to PayFlex for a review of the claim at the address indicated below. The request must be made within 60 days after the claim is denied. If you do not file a written request for review of a claim denial within that 60-day period, you will have no further right to review and no right to bring action in any court, and the denial of the claim shall be final and binding. Within 60 days after a written request for a review is received, you or your beneficiary will receive a written notice of the final decision or of the reason for the delay in reaching a final decision if special circumstances require an extension of time. In any event, a final decision will be reached, and you will be notified within 120 days after your written request for review is received. The decision on review will be final and binding on all persons for all purposes. Issues of eligibility to participate or enroll in the Plan will be determined by the Plan Administrator in accordance with the above requirements. If you have questions on the appeal process, contact PayFlex at (800) or the McDonald s Service Center at (877) File your appeal with PayFlex at the following address: PayFlex Systems USA, Inc. Attn: Reimbursement Accounts P.O. Box 3039 Omaha, NE

143 Some Dependent Care Spending Account Guidelines The Dependent Care Spending Account Plan must comply with the following additional IRS rules: You should remember that once you decide how much to put in your Dependent Care Spending Account, you cannot transfer funds between your Dependent Care Spending Account and your Healthcare Spending Account. You cannot change or stop the amount deducted, unless you experience a qualifying life event change. Reimbursement (i) from different dependent care spending accounts for the same expense; (ii) for an expense that s already been fully covered under another benefit plan; (iii) for an expense that is not an eligible expense; or (iv) for the care of an individual who is not your Dependent under federal tax rules is not permissible and is against federal law. By filing a Dependent Care Spending Account claim you are stating that those expenses are eligible for reimbursement and are not reimbursed from another source. PayFlex Service Center You can use the PayFlex website at to check your Dependent Care Spending Account balance, obtain claim forms and instructions, perform transactions, obtain a direct deposit form to have reimbursements sent directly to your bank account, and more. You will need to register as a user before you can access certain information and features. Special Rules if You Change Your Employment Status If your employment status changes, the following special rules apply: Termination of Employment/Change to an Ineligible Class. If your employment terminates or you are transferred to a class of Employees that is not eligible to participate in the Dependent Care Spending Account Plan, all contributions to your Dependent Care Spending Account will stop. If you still have money in your Dependent Care Spending Account, you can continue to submit claims through May 31 st of the following year to pay for eligible expenses incurred before the end of the month in which your termination or employment change occurred. Leave of Absence. If you go on an unpaid medical, personal or military leave of absence, your contributions will cease. If you still have money in your Dependent Care Spending Account, you can continue to submit claims through May 31 st of the following year to pay for eligible expenses incurred before the end of the month in which your leave of absence begins. Note that if you are on Short Term Disability for more than a few weeks and your Spouse is not working, you will not be able to submit claims for reimbursement for periods during which you were not working. You are not eligible to make Dependent Care Spending Account contributions while you are on Long Term Disability. If you return to work in the same Plan Year to an eligible class, you may elect to resume your Dependent Care Spending Account contributions at your prior rate. If you return in a different Plan Year, you may make a new election for Dependent Care Spending Account contributions. In either case, you must make an election to resume contributions within 60 days of your return to work. When Your Participation in the Dependent Care Spending Account Ends In addition to the situations for terminating your Dependent Care Spending Account contributions described above, you will no longer be eligible to participate in the Dependent Care Spending Account Plan after the earliest to occur of the following: You stop making contributions. The Plan stops. The Plan is amended so that coverage will end for an entire group of Employees and you are in that group. If your participation ends for one of the above reasons, you can submit claims through May 31 st of the following year for reimbursement to pay for eligible expenses incurred before your participation ended. 139

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145 REFERENCE INFORMATION & GLOSSARY

146 THIS INFORMATION APPLIES TO: Full & Part-Time Staff Restaurant Employees in the following positions: General Manager Department Manager Certified Swing Primary Maintenance Benefits-Eligible Crew 141

147 ADMINISTRATIVE INFORMATION Plan Sponsor The sponsor for your Health Plan (Medical, Vision Supplement and Dental), Group Insurance Plan (Life, AD&D, Travel Accident, Business Travel Accident and Long Term Disability Insurance), Employee Resource Connection, Healthcare Spending Account Plan and Dependent Care Spending Account Plan is: McDonald's Corporation 2111 McDonald s Drive Oak Brook, IL (630) Plan Administrator McDonald s Corporation has delegated the responsibility for the day-to-day administration of the Plans to the Plan Administrator. The current Plan Administrator is: McDonald s Corporation Welfare Plan Administrative Committee Dept. # McDonald s Drive Oak Brook, IL (630) The Plan Administrator has discretion to interpret Plan provisions and its decisions are final, binding and complete with respect to participants and beneficiaries. The Plan Administrator has delegated this discretion with respect to claims and appeals under the Plan other than eligibility claims and appeals as follows: To the extent benefits under the Plans are funded through insurance policies (including HMOs/DHMOs), the insurer is the claim fiduciary with respect to those benefits. In that case, the insurer has the discretion to interpret the policy as it applies to a claim or appeal and its decisions are final and binding. With respect to the Medical, Dental, and Healthcare Spending Account Plans and the Employee Resource Connection, the Claims Administrator, in accordance with its agreement with McDonald s, has the discretion to interpret the Plan provisions as they apply to a claim or appeal and its decision is final and binding. Employer Number The federal government has assigned McDonald's an employer identification number for the Plans. It is (EIN): The employer identification number for the Trust funding your Medical, Vision Supplement and Dental Plans is (EIN): Terminations and Amendments It is McDonald's intent that the Plans continue indefinitely; however, it reserves the right to end, suspend or withdraw any or all of the Plans or any trust funding the Plans or any part of the Plans or trust at any time. McDonald s also has the right to amend the Plans and any trust funding the Plans, including the power to change, reduce or eliminate benefits or change contribution levels available under any part of the Plan for all or any group of Employees. McDonald s has delegated this amendment power to the Compensation Committee of the Board of Directors. The Compensation Committee has delegated to the Plan Administrator the authority to amend and/or terminate the following Plans: Health Plan: Dental, Vision Supplement Plan and any HMOs components. Group Insurance Plan: Life, AD&D, Business Travel Accident and Long Term Disability Insurance. Premium Payment Plan. 142

148 Dependent Care Spending Account Plan. Healthcare Spending Account Plan. Employee Resource Connection. Welfare Benefit Trust (VEBA). The Compensation Committee has also delegated to the Plan Administrator the authority to adopt the following amendments to the Medical Plan: Amendments that the Plan Administrator deems necessary or desirable to comply with or obtain advantages of applicable law, regulations or rulings; and Any procedural or administrative amendments that the Plan Administrator deems necessary or desirable that do not materially decrease benefits or materially increase Company contributions to the Plan. All amendments made by the Company, the Compensation Committee or the Plan Administrator are final and binding. Finally, the Plan Administrator has the authority, in its discretion, to: Waive part or all of the eligibility, Deductible, Copay, Coinsurance or Out-of-Pocket Maximum provisions of the Plans as it may deem necessary or desirable to effectuate the transition of any employee or group of employees acquired by the Company through merger, acquisition, international assignment or other corporate action; or Waive certain provisions of the Plans in such manner and for such period of time as necessary or desirable to assist employees who are victims of a disaster or act of terrorism. Any such waivers, however, shall be done only in a nondiscriminatory manner and only to the extent that it is permissible under any governing Plan documents, trust agreements or contracts and applicable law. Claims Administrators Blue Cross and Blue Shield of Illinois (Medical/Dental) 300 East Randolph Street Chicago, IL (800) PayFlex (Healthcare and Dependent Care Spending Accounts) Attn: Reimbursement Accounts P.O. Box 3039 Omaha, NE (800) EyeMed Vision Care (Vision Supplement) P.O. Box 8504 Mason, OH (866) ComPsych (Employee Resource Connection and Mental Health/Substance Abuse Benefits) NBC Tower, 13 th Floor 455 N. Cityfront Plaza Drive Chicago, IL (888) CVS Caremark (Prescription Drug Program) P.O. Box Richardson, TX (866) Aetna - Basic and Optional Group Life Insurance and AD&D Insurance 151 Farmington Ave. Hartford, CT

149 MetLife Long Term Disability Insurance MetLife P.O. Box Lexington, KY Cigna - Business Travel Accident Insurance Life Insurance Company of North America 1600 W. Carson Street, Suite 300 Pittsburgh, PA Employee and Dependent Data In order to receive benefits under the Plans, it is important that you keep the McDonald s Service Center informed of your current Dependent and/or beneficiary information and keep that information updated. Also, you must keep the McDonald s Service Center informed of your correct address. Any communication, statement or notice addressed to you and/or your Dependents or beneficiaries at your last address filed with the McDonald s Service Center will be binding. The Company has no legal obligation to search for or investigate the whereabouts of any person benefiting under the Plans. Agent for Service of Legal Process The agent for service of legal process of the Plans: McDonald's Corporation c/o Gloria Santona, General Counsel 2111 McDonald s Drive Oak Brook, IL (630) Governing Law The Plans will be construed and enforced according to the laws of the State of Illinois to the extent not preempted by ERISA. Plan Year Information Health Plan Medical, Dental and Vision Supplement Group Insurance Plan Life Insurance AD&D and Travel Accident Insurance Business Travel Accident Insurance Long Term Disability Insurance Healthcare Spending Account Plan Dependent Care Spending Account Plan Premium Payment Plan Employee Resource Connection December 1 st - November 30 th January 1 st - December 31 st January 1 st - December 31 st January 1 st - December 31 st January 1 st - December 31 st January 1 st - December 31 st Plan Filing and Funding Information The chart at the end of this section shows certain Plan filing and funding information, as required by the Employee Retirement Income Security Act of 1974 (ERISA), as amended. 144

150 Trustee of McDonald s Corporation Welfare Benefit Trust (VEBA) J.P. Morgan Chase Bank, NA JPMorgan Chase Bank, Wss-Client Service Post Office Box Columbus, OH Health Plan funds are held in the VEBA Trust. Your ERISA Rights As a participant in the Plans, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Plan participants shall be entitled to: Receive Information about Your Plan and Benefits Examine, without charge, at the Plan Administrator's Office and at other specified locations, all documents governing the Plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Pension and Welfare Benefit Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and copies of the latest annual report (Form 5500 Series) and an updated summary plan description. The Plan Administrator may make a reasonable charge for the copies. Receive a summary of the Plan s annual financial reports. The Plan Administrator is required by law to furnish each participant with a copy of these summary annual reports. Continue Group Health Plan Coverage Continue healthcare coverage for yourself, Spouse, Domestic Partner or Dependent children if there is a loss of coverage under the Medical, Dental, Vision Supplement, Employee Resource Connection and Healthcare Spending Account Plans as a result of a qualifying event. You or your Spouse, Domestic Partner or Dependents may have to pay for such coverage. Review this Summary Plan Description and the documents governing those Plans on the rules governing your COBRA continuation coverage rights. Reduction or elimination of exclusionary periods of coverage for Pre-Existing Conditions under the Medical, Vision Supplement and Dental Plan, if you have creditable coverage from another plan. You should be provided a certificate of Creditable Coverage, free of charge, from the Medical, Vision Supplement and Dental Plan when you lose coverage, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it 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 up to12 months from your effective date of coverage or, if you had a waiting period for coverage, from the first day of your waiting period. 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 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, your union, 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 welfare benefit is denied or ignored, in whole or part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal 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 a copy of Plan documents or the latest annual report 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 control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the Plan s decision or lack thereof concerning the qualified status of a medical child support order, you may 145

151 file suit in 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 U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal 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 is frivolous. Assistance with Your Questions If you have any questions about your Plan, you should contact the McDonald s Service Center. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publication s hotline of the Employee Benefits Security Administration. This Summary Plan Description contains highlights of McDonald s policies and benefits. For complete details you should consult the official Plan documents as they will govern in the case of any discrepancy. 146

152 ADMINISTRATIVE SUMMARY Plan Names Plan # Type of Plan Funding Vehicle Administered By McDonald s Corporation Health Plan McDonald s Corporation Group Insurance Plan McDonald s Corporation Premium Payment Plan McDonald s Corporation Dependent Care Spending Account Plan McDonald s Corporation Healthcare Spending Account Plan McDonald's Corporation Employee Resource Connection 501 Self-insured welfare plan providing medical, dental and vision supplement benefits (fully insured for HMOs/DHMOs) 504 Fully insured welfare plan providing life, AD&D, business travel accident and long term disability insurance 506 Cafeteria plan under Section 125 of IRC for medical, dental and vision supplement premiums 507 Cafeteria plan under Section 129 of IRC allowing pre-tax deductions from income for day care expenses 508 Cafeteria plan under Section 125 of IRC allowing pre-tax deductions from income for healthcare expenses 522 Welfare plan providing employee assistance benefits Voluntary Employee s Beneficiary Association (VEBA) under Section 501(c)(9) of the Internal Revenue Service Code Aetna (life and AD&D insurance) MetLife (long term disability insurance Cigna ( business travel accident insurance) VEBA General Assets of McDonald s Corporation General Assets of McDonald s Corporation General Assets of McDonald s Corporation McDonald's Corporation, BCBSIL (Medical/Dental), EyeMed Vision Care (Vision Supplement), ComPsych (Mental Health/Substance Abuse), Kaiser (HMO), HMSA (HMOs/DHMOs), and Netcare (HMOs/DHMOs) McDonald s Corporation and Aetna, MetLife or Cigna, as applicable McDonald s Corporation McDonald s Corporation and PayFlex McDonald s Corporation and PayFlex McDonald s Corporation and ComPsych 147

153 GLOSSARY Actively at Work or Active Work Adverse Benefit Determination Ambulatory Surgical Center Benefits-Eligible Crew Brand Name Drug Performing all of the usual and customary duties of your job at your Employer's place of business, an alternative place approved by your Employer or a place to which your Employer requires you to travel. You will be considered to be Actively at Work during weekends or Employer approved vacations, holidays or business closures if you were Actively at Work on the last scheduled work day preceding that time off. For purposes of Medical, Dental, Employee Resource Connection and Healthcare Spending Account appeals, a denial, reduction, or termination of or failure to provide or make payment (in whole or in part) for a benefit, including any such denial, reduction, termination, or failure to provide or make payment for a benefit resulting from the application of utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate or because there has been a coverage rescission. If an ongoing course of treatment had been approved by the Claims Administrator and the Claims Administrator reduces or terminates such treatment (other than by amendment or termination of the Plan) before the end of the approved treatment period, that is also an Adverse Benefit Determination. A public or private facility, licensed and operated according to the law, which does not provide services or accommodations for a patient to stay overnight. The facility must have an organized medical staff of Physicians, maintain permanent facilities equipped and operated primarily for the purpose of performing surgical procedures, supply registered professional nursing services whenever a patient is in the facility and be Medicare-approved or accredited as an ambulatory surgical facility by the Joint Commission on Accreditation of Healthcare Organizations. A Crew Employee who works on average 30 hours/week over a 12-month period as calculated in the Eligibility and Enrollment for Benefits-Eligible Crew section. A Brand Name Drug is a Prescription Drug that complies with the Food and Drug Administration s (FDA) standards, is an innovator drug, and is, or was at one time, under patent protection. Calendar Year A period of one year beginning with January 1 st. Coinsurance/Copay COBRA Coma Cosmetic Surgery The amount you are required to pay for a covered expense after the Deductible is satisfied or for a Prescription Drug through CVS Caremark. (The Deductible is not applicable to Prescription Drug coverage through CVS Caremark.) The Consolidated Omnibus Budget Reconciliation Act of 1985, as amended. A profound state of unconsciousness from which the Covered Person is not likely to be aroused through powerful stimulation. The Coma must begin within 30 days of the covered accident, continue for 60 consecutive days and be diagnosed and treated regularly by a Physician. Coma does not mean any state of unconsciousness intentionally induced during the course of treatment of a covered injury unless the unconsciousness results from the administration of anesthesia in preparation for surgical treatment of injuries sustained in that covered accident. Medically unnecessary surgical procedures, usually but not limited to, plastic surgery directed toward preserving beauty or correcting scars, burns or disfigurements. 148

154 Covered Person Crew Employee Custodial Care Deductible Dentist Dependent Domestic Partner An Employee or Dependent who is covered under the Medical/Dental/Vision Supplement or Group Insurance Plans. Any restaurant Employee other than a General Manager, Department Manager, Certified Swing Manager or Primary Maintenance Employee. Services and supplies furnished primarily to assist an individual in the activities of daily living. Activities of daily living include such things as bathing, feeding, administration of oral medicines or other services that can be provided by persons without the training of a health care Provider. The amount you pay for yourself and/or each covered Dependent in a Calendar Year before benefits are payable. A person who is properly trained and licensed to practice dentistry and who is practicing within the scope of such license. Your Spouse, Domestic Partner and/or family member who meets the criteria for a Dependent under the applicable Plan. Your same sex or opposite sex partner, as long as you meet all of the following criteria that you and your partner: Are in a mutually exclusive relationship, are each other s sole Domestic Partner, have been so for at least six months and intend to remain so indefinitely. Are both at least 18 years of age (or at least the age of consent in the state in which you live). Are not related closely enough by blood to bar marriage in the state in which you reside. Reside together in the same principal residence, have done so for at least the past six months and intend to do so indefinitely. Have joint responsibility for each other s welfare and financial obligations and can upon request show evidence of such responsibility in two of the following forms: Registration in a state or locality that allows for registration of Domestic Partners; or Joint mortgage, lease or deed; or Joint bank account; or Joint credit cards; or Designation of the Domestic Partner as beneficiary for life insurance, retirement benefits, will or trust; or Durable property or health care power of attorney. Unless otherwise noted, for purposes of the Health Plan (including Medical, Dental and Vision Supplement), the Group Insurance Plan (including Life, AD&D, Business Travel Accident and Long Term Disability Insurance) and the Employee Resource Connection, a Domestic Partner is treated the same as a Spouse. For purposes of coverage under these Plans, you and your Domestic Partner will be asked to sign an affidavit to verify that you meet these requirements. The affidavit is available on AccessMCD or from the McDonald s Service Center by calling (877) In addition, a Notice of Termination of Domestic Partnership must be submitted within 60 days of the date you no longer meet the criteria. Eligible Employee For purposes of the Health Plan, Eligible Employee means a Full-Time or Part-Time Staff, Restaurant General Manager, Department Manager, Certified Swing Manager, Primary Maintenance or Benefits-Eligible Crew Employee on the U.S. payroll of McDonald s. For purposes of all other benefits in this SPD, Eligible Employee means all of the Employees listed in the previous sentence other than Benefits-Eligible Crew. 149

155 Emergency Emergency Services Emergency Diagnosis A sudden, serious, unexpected and acute onset of an illness or Injury where a delay in treatment could cause irreversible deterioration resulting in a threat to the patient s life or a body part, or an organ not returning to full, normal function. Emergency Services are those services provided by a Physician or other appropriate Provider to treat an Emergency. A diagnosis of such conditions that include, but are not limited to, suspected heart attack or stroke, loss of consciousness, actual or suspected acute poisoning, acute appendicitis, toxicity due to drugs or alcohol, acute renal failure, heat exhaustion, convulsive disorder, severe hemorrhage/allergic reaction, airway obstruction or aspiration, emergency medical care rendered for an accidental Injury and other acute conditions. Examples of Non-Emergency Diagnosis include, but are not limited to: Upper respiratory tract infection, urinary tract infection, earache, sore throat, general flu-like symptoms, gastritis and gastroenteritis (e.g., diarrhea, vomiting), minor headache (not requiring intramuscular medication), minor backache (not requiring intramuscular medication), suture removal or follow-up care, first degree burns, symptoms of greater than 3-day duration, and more than one visit to the emergency room for same condition. Employee Employer ERISA Exacerbation Experimental and/or Investigational A person who is an employee on the U.S. payroll of McDonald s Corporation or any other Employer that has adopted the Plans, regularly scheduled to work for McDonald s or an Employer in an employee/employer relationship. Employee does not include a person who is (or is an employee of) a contractor, a consultant, an independent contractor or a leased employee within the meaning of Internal Revenue Code Section 414(n)(2) ( Leased Employee ), whether or not such person is or is subsequently determined to be a common law employee of McDonald s. An individual who performs services for McDonald s as (or as an employee of) a contractor, a consultant, an independent contractor or a Leased Employee shall not become an Employee because of being reclassified by the Internal Revenue Service or another government agency, except prospectively from the date on which such reclassification occurs and is accepted by McDonald s. McDonald s Corporation and any commonly controlled entity that has adopted the Plans. A commonly controlled entity is any corporation, trade or business that is within the McDonald s controlled group of corporations as defined in IRS Code Section 414(b), under common control as defined in IRS Code Section 414(c), members of an affiliated service group as defined in IRS Code Section 414(m), or members of a group required to be aggregated under IRS Code Section 414(o). The Employee Retirement Income Security Act of 1974, as amended. Aggravation of symptoms or increase of severity of disease. Services, supplies, care and treatment which do not constitute accepted medical practice properly within the range of appropriate medical practice under the standards of the case and by the standards of a reasonably substantial, qualified, responsible, relevant segment of the medical community or government oversight agencies at the time services were rendered. The Claims Administrator must make an independent evaluation of the experimental/non-experimental standings of specific technologies. The Claims Administrator Committee shall be guided by a reasonable interpretation of Plan provisions. The decisions shall be made in good faith and rendered following a detailed factual background investigation of the claim and the proposed treatment. The Claims Administrator will be guided by the following considerations: 150

156 If the drug or device has not received the approval of the U.S. Food and Drug Administration for marketing; or If the drug, device, medical procedure or treatment is the subject of ongoing phase I, II or III clinical trials or is otherwise under study to determine its toxicity, its safety, or its efficacy; or If reliable evidence shows that the prevailing opinion among experts regarding the drug, device, medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety or its efficacy as compared with a standard means of treatment or diagnosis. Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature; the written protocol(s) used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, medical treatment or procedure. In any event, if you participate in an approved clinical trial, your eligible expenses will be covered to the extent required under the Affordable Care Act. Full-Time Staff Employee regularly scheduled to work at least 35 hours per week. Generic Drug Genetic Information Home Healthcare Agency Home Healthcare Plan A Prescription Drug, which has the equivalency of the Brand Name Drug with the same use and metabolic disintegration. The Medical Plan will consider a Generic Drug any Food and Drug Administration-approved generic pharmaceutical dispensed according to the professional standards of a licensed pharmacist and clearly designated by the pharmacist as being Generic. 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 laboratory tests that identify mutations in specific genes or chromosomes, physical medical examinations, family medical histories and direct analysis of genes or chromosomes. A public or private agency or organization licensed and operated according to the law that specializes in providing medical care and treatment in the home. The agency must have policies established by a professional group; have at least one Physician and one registered nurse (R.N.) to supervise the services provided; and be Medicare-approved or accredited by the Joint Commission on Accreditation of Healthcare Organizations. The Plan must include all of the following requirements: Be a formal written plan made by the patient s attending Physician that is reviewed at least every 30 days. State the diagnosis. Certify that the home healthcare is Medically Necessary. Specify the type and extent of home healthcare required for the treatment of the patient. Home Healthcare Services and Supplies Hospice Agency Hospice Care Plan Includes part-time or intermittent nursing care by or under the supervision of a registered nurse (R.N.); part-time or intermittent home health aide services provided through a Home Healthcare Agency (this does not include general housekeeping services); physical, occupational and speech therapy; medical supplies; and laboratory services by or on behalf of the Hospital. An agency whose function is to provide Hospice Care Services and Supplies and who is licensed by the state in which it is located, if licensing is required. A plan of terminal patient care that is established and conducted by a Hospice Agency and supervised by a Physician. 151

157 Hospice Care Services and Supplies Hospice Facility or Unit Are those provided through a Hospice Agency and under a hospice care plan and includes Inpatient Care in a Hospice Unit or other licensed facility, home care and family counseling during the bereavement period. A public or private organization or separate Hospital unit, licensed and operated according to the law, primarily engaged in providing palliative, supportive, and other related care for a Covered Person diagnosed as terminally ill. The facility must have an interdisciplinary medical team consisting of at least one Physician, one registered nurse, one social worker, one volunteer and a volunteer program. The facility must be Medicare-approved or accredited by the Joint Commission on Accreditation of Healthcare Organizations. A hospice facility is not a facility or part thereof which is primarily a place for rest, custodial care, the aged, drug addicts, alcoholics or a hotel or similar institution. Hospital A public or private facility licensed and operated according to the law, which provides care and treatment by Physicians and nurses of an Illness or Injury through medical, surgical and diagnostic facilities on its premises at the patient s expense. The facility must be Medicare-approved or accredited by the Joint Commission on Accreditation of Healthcare Organizations. A Hospital does not include a facility or any part thereof which is a place for rest, the aged or convalescent care. Hours of Service Injury Intensive Care Unit Inpatient Care Lifetime Maintenance Care Medical Care Facility Medically Necessary/ Medical Necessity Each hour for which you are paid, or entitled to payment: (i) for hours you work for your Employer or (ii) for vacation, holiday, illness, incapacity (including disability), layoff, jury duty, military duty or leave of absence. An accidental physical injury to the body caused by unexpected external means. A separate, clearly designated service area which is maintained within a Hospital solely for the care and treatment of patients who are critically ill. This also includes what is referred to as a coronary care unit or an acute care unit. The unit must have facilities for special nursing care not available in regular rooms and wards of the Hospital; special lifesaving equipment which is immediately available at all times; at least two beds for the accommodation of the critically ill; and at least one registered nurse (R.N.) in continuous and constant attendance 24 hours a day. Hospital care that requires charges for room and board for the appropriate treatment. A word that appears in the Medical Plan in reference to benefit maximums and limitations. Lifetime is understood to mean while covered under the Medical Plan. Under no circumstances does Lifetime mean during the lifetime of the Covered Person. Service which does not change the patient s condition but rather maintains the current condition or prevents deterioration, usually treats a permanent, chronic or irreversible condition and addresses treatment plan goals that remain constant. A Hospital or a facility that treats one or more specific ailments or any type of skilled nursing facility. Healthcare services and supplies that are: Recommended or approved by a Physician for treatment of a medical condition; 152

158 Consistent in type, frequency and duration of treatment based on guidelines of appropriate national medical, research or healthcare coverage organizations or government agencies; Consistent with the diagnosis of the condition; Required for reasons other than the convenience of the Covered Person or his or her Physician; The most cost-effective method available to treat the medical condition; and Demonstrated through peer-reviewed medical literature to be either: - Safe and effective for treating or diagnosing the medical condition, or - Safe with promising effectiveness for (i) treating a life-threatening medical condition, (ii) in a controlled research setting, (iii) using protocol that is equivalent to standards set by the National Institutes of Health. For purposes of this definition, the term medical condition means a disease, Sickness or Injury, including Mental Disorder. The fact that a Physician may prescribe, order, recommend or approve a service, medicine or supply does not, in and of itself, make it Medically Necessary. Medicare Mental Disorder Modality Morbid Obesity Occupational Therapy Outpatient Care Part-Time Pharmacy Physician Pre-Determination of Dental Benefits Title XVIII (Health Insurance for the Aged and Disabled) of the United States Social Security Act as amended. Any disease or condition that is classified as a Mental Disorder in the current edition of International Classification of Diseases, published by the U.S. Department of Health and Human Services or is listed in the current edition of Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. Physical application of any therapeutic agent, e.g., traction, hot pack, cold pack, ultra sound, electrical stimulation (manual). A Spinal Manipulation is considered separately from the Modalities allowed. A diagnosed condition in which the body weight exceeds the normal weight by either 100 pounds or is twice the normal weight of a person the same height, and conventional weight reduction measures have failed. The excess weight must cause a medical condition such as physical trauma, pulmonary and circulatory insufficiency, diabetes or heart disease. Treatment of a physically disabled Covered Person by means of constructive activities designed and adapted to promote the restoration of the person s ability to accomplish satisfactorily the ordinary tasks of daily living and those required by the person s particular occupation. Treatment either outside of a Hospital setting or at a Hospital when room and board charges are not incurred. Staff Employee regularly scheduled and working at least 20 hours per week. A licensed establishment where covered Prescription Drugs are filled and dispensed by a pharmacist licensed under the laws of the state where he or she practices. A person acting within the scope of his/her license and holding the degree of Doctor of Medicine (M.D.) including a Psychiatrist or Doctor of Osteopathy (D.O.) and who is legally entitled to practice medicine under the laws of the state or jurisdiction where the services are rendered. A way of telling ahead of time how much will be paid for dental services, to help avoid surprises. Have your Provider submit a benefit determination request to BCBSIL outlining what work needs to be done. The Provider lists the services and charges on the form and sends it to BCBSIL. BCBSIL tells you and the Provider what amount the 153

159 Plan will pay. If a Pre-Determination of Benefits is not used for Dental, payment will be based on whatever information BCBSIL has about the case. Pregnancy Prescription Drug Pre-Service Claim Providers Childbirth and conditions associated with Pregnancy, including complications. Any of the following: a drug or medicine which, under federal law, is required to bear the legend: Caution: federal law prohibits dispensing without prescription ; injectable insulin, hypodermic needles or syringes, but only when dispensed upon a written prescription; and birth control pills and contraceptive injectable and devices. A request for approval of a benefit in advance of obtaining the medical or dental care, for example, a request for a Pre-Determination of Dental Benefits. A Physician or person acting within the scope of applicable state licensure/certification requirements and holding the degree of Doctor of Dental Surgery (DDS), Doctor of Podiatry (DPM), Doctor of Chiropractic (DC), Doctor of Optometry, Psychologist (Ph.D.), Licensed Professional Physical Therapist, Physiotherapist, Licensed Professional Counselor, Audiologist, Speech-Language Pathologist, Midwife and any other practitioner of the healing arts who is licensed and regulated by a state or federal agency and is acting within the scope of his or her license. The use of an adjective such as participating in modifying a Provider shall in no way be construed as a recommendation, referral or other statement as to the ability or quality of the Provider. In addition, the omission, non-use or non-designation of participating or any similar modifier or the use of a term such as non-participating should not be construed as carrying any statement or inference, negative or positive, as to the skill or quality of such Provider. Each Provider provides Covered Services only to you and does not deal with or provide any services to the Company or the Plan. Post-Service Claim Psychologist A claim for payment or reimbursement of costs for medical or dental care that has already been provided. A person who specializes in clinical psychology and fulfills one of these requirements: A person licensed or certified as a Psychologist by the appropriate governmental authority; or A Member or Fellow of the American Psychological Association, if there is no governmental licensure or certification required. Reasonable and Customary/R&C For Mental Health/Substance Abuse charges, Reasonable and Customary means the charge as determined by ComPsych that is most frequently made to the majority of patients for the same service or procedure. The charge must be within the range of the charges most frequently made in the same or similar service area for the service or procedure as billed by other Providers. For medical and dental charges, Reasonable and Customary means the charge determined by BCBSIL that is equal to the lesser of: The Provider s billed charges; or The eligible charge as determined by BCBSIL, which is developed from base Medicare reimbursements and represents approximately 300% of the base Medicare reimbursement rate and will exclude any Medicare adjustment(s) which are based on the information on the claim. Reasonable and Customary does not apply to Providers participating in the BCBSIL PPO or ComPsych network, as applicable. You will be responsible for paying expenses above those charges that are considered Reasonable and Customary. Rehabilitation Program A program that has been approved by MetLife for the purpose of helping you to return to work. It may include, but is not limited to, your participation in one or more of the 154

160 following activities: Return to work on a modified basis with a goal of resuming employment for which you are reasonably qualified by training, education, experience and past earnings. On-site job analysis. Job modification/accommodation. Training to improve job-seeking skills. Vocational assessment. Short-term skills enhancement. Vocational training. Restorative therapies to improve functional capacity to return to work. Root Canal Therapy Sickness Skilled Nursing Facility Skilled Nursing Service Social Worker Treatment of a tooth having a damaged pulp. Usually performed by completely removing the pulp (endodontic therapy), sterilizing the pulp chamber and Root Canals, and filling the spaces with sealing material. A person s illness, disease or Pregnancy (including complications). A public or private facility, licensed and operated according to the law, which provides: permanent and full-time facilities for 10 or more resident patients; a registered nurse or Physician on full-time duty in charge of patient care; at least one registered nurse or licensed practical nurse on duty at all times; a daily medical record for each patient; transfer arrangements with a Hospital; and a utilization review plan. The facility must be primarily engaged in providing continuous skilled nursing care for persons during the convalescent stage of their Sickness or Injury and is not a rest home for custodial care or for the aged. The facility must be Medicare-approved or accredited by the Joint Commission on Accreditation of Healthcare Organizations. Those services provided by a registered nurse (R.N.) or licensed practical nurse (L.P.N.) that require the technical abilities and professional training of an R.N. or L.P.N. and that cannot reasonably be taught to a person who does not have specialized abilities and professional training. Skilled Nursing Service includes any service provided under the direction of a Physician that requires assessment, intervention, and treatment for the cure or alleviation of the symptoms of a Sickness, accidental Injury or Pregnancy. In states where government licensing or certifications exist, a licensed or certified Social Worker for psychological testing and psychotherapy in connection with Mental Health conditions or Substance Abuse treatment. The Social Worker must be licensed or certified under the laws of the jurisdiction in which such person renders services to you or your Dependent. In states where no government licensing or certifications exist, Social Worker s services as outlined above provided by a Social Worker who is a member in good standing of the Academy of Certified Social Workers (ACSW). Psychological testing and psychotherapy by a Qualified Social Worker do not have to be recommended and approved by a Physician. Spouse Spinal Manipulation/ Chiropractic Care Substance Abuse The person to whom the Employee is legally married. Skeletal adjustments, manipulation or other treatment in connection with the detection and correction by manual or mechanical means of structural imbalance or subluxation in the human body. Such treatment is done by a Provider to remove nerve interference resulting from, or related to, distortion, misalignment or subluxation of, or in, the vertebral column. The condition caused by regular excessive compulsive drinking of alcohol and/or physical habitual dependence on drugs that results in a chronic disorder affecting 155

161 physical health and/or personal or social functioning. This does not include dependence on tobacco and ordinary caffeine-containing drinks. Surgical Assistant Temporomandibular Joint (TMJ Syndrome) Treatment Center A non-physician trained to assist a surgeon (e.g., operating room technician, Physician s assistant, and nurse). The treatment of jaw joint problems including conditions of structures linking the jaw bone and skull and the complex of muscles, nerves and other tissues related to the Temporomandibular Joint. Care and treatment includes, but is not limited to orthodontics, crowns, inlays, physical therapy and any appliance that is attached to or rests on the teeth. A facility that meets the following requirements: It is established and operated in accordance with any applicable state law. It provides a program of treatment approved by a Physician and the Plan Administrator. It has or maintains a written, specific and detailed regimen requiring full-time residence and full-time participation by the patient. It provides at least the following basic services: - Room and Board (if the Medical Plan provides for In-patient benefits at a Treatment Center). - Evaluation and diagnosis. - Counseling. - Referral and orientation to specialized community resources. Treatment Centers which qualify as a Hospital are covered as a Hospital and not as a Treatment Center. Urgent Care Claim A claim for medical or dental care where applying the time periods for Pre- or Post- Service Claims decisions could seriously jeopardize the Covered Person s life, health or ability to regain maximum function or would subject the Covered Person to severe pain that cannot be adequately managed without the care that is the subject of the claim. If the treating Physician determines the claim is urgent, the Plan will treat the claim as an Urgent Care Claim. Document #: v6 156

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163 2014 McDonald s. Creative Services 16367