Choices Competitive Coverage

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1 Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Wellness Choices Competitive Coverage Plan Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage Protection Health Care Retirement Work/Life Benefits Flexibility Choices Competitive Coverage

2 Important Notice This Summary Plan Description (SPD) booklet, including any subsequent related Summaries of Material Modifications (SMMs), is intended to help you understand the main features of The Prudential Wellness Plan (the Plan ) applicable to eligible Employees and to provide information regarding your benefits. This SPD booklet, including any subsequent related SMMs, constitutes the latest SPD booklet of the Plan. The Plan also covers other classes of Employees as described in other SPD booklets that cover those specific Employee populations. This SPD booklet, including any subsequent related SMMs, is not a substitute for the official Plan Document(s) that governs the operation of the Plan. All terms and conditions of the programs under the Plan, including your eligibility and any benefits, will be determined pursuant to and are governed by the provisions of the applicable Plan Document(s). If there is any discrepancy between the information in this SPD booklet, including any subsequent related SMMs, or in any other Prudential materials relating to the programs and the actual Plan Document(s), or if there is a conflict between information discussed by anyone acting on Prudential s behalf and the actual Plan Document(s), the Plan Document(s) as interpreted by the applicable Plan Administrator in its sole discretion will always govern. Prudential may, in its sole discretion, modify, amend, suspend or terminate any and all of its HR policies, programs, Plans, and benefits, including those described in this SPD booklet, including any subsequent related SMMs, in whole or in part, at any time, without notice to or consent of any participant, employee or former employee to the extent permissible under applicable law. Nothing contained in this SPD booklet, including any subsequent related SMMs, is intended to constitute or create a contract of employment, nor shall it constitute or create the right to remain associated with or in the employ of Prudential for any particular period of time. In addition, no oral or written statements made by anyone acting on Prudential s behalf are intended to create the right to remain associated with or in the employ of Prudential for any particular period of time. Employment with Prudential is employment-at-will. This means that either you or Prudential may terminate the employment relationship at any time, with or without cause or notice. The Prudential Wellness Plan Page i

3 Inside You Will Find... Introduction to The Prudential Wellness Plan... 1 How to Contact the Prudential Benefits Center... 2 Online Access... 2 Via the Internet... 2 Telephone Access... 2 Mail Access... 2 Viewing this SPD Booklet Online... 2 Terms and Conditions... 2 Joining the Plan... 3 Who Is Eligible... 3 Who Is Not Eligible... 3 Qualified Dependent Eligibility... 4 Your Child Age 26 or Older, a Child Living in Your Home for Whom You Are the Legal Guardian and Your Grandchild Must Be Your Qualifying Child or Your Qualifying Relative... 6 Special Exception Related to Multiple Support Agreements for a Child Who Has Attained at Least Age 26 and for a Grandchild... 6 Certification Form... 6 Qualified Medical Child Support Order... 6 When You Are Eligible to Enroll... 7 How to Enroll... 7 When Coverage Takes Effect... 7 Cost of Coverage... 7 How the Plan Works... 8 Employee Assistance Program (EAP)... 9 Eligibility... 9 Covered Services... 9 Coverage Limitations... 9 Accessing the Program Cost of Coverage Clinic Program Eligibility Covered Services Coverage Limitations Accessing the Program Cost of Coverage Health Coaching Program Eligibility Covered Services Coverage Limitations Accessing the Program Cost of Coverage The Prudential Wellness Plan Page ii

4 Best Doctors Program Eligibility Covered Services Coverage Limitations Accessing the Program Cost of Coverage Other Important Information When Your Coverage Ends When Qualified Dependent Coverage Ends Notification If You Are Disabled If You Take a Leave of Absence If You Retire Administrative Information Plan Administration and Funding Plan Name and Number Plan Administrator Plan Sponsor Employer Identification Number Plan Year Funding, Payment and Claims of Plan Benefits Administrators Plan Amendment or Termination Assignment of Benefits National Medical Support Notice Claims, Claims Appeals and External Claims Review Procedures Claim for Benefits Making a Claim for a Benefit What Information to Include in a Claim When to File a Claim Urgent Care Claims Concurrent Care Claims Pre-Service Claims Post-Service Claims Notice of Adverse Benefit Determination Appeal of an Adverse Benefit Determination How to File a Claim for Benefits Access to Records Appeals Procedures Time for Determination Notice of Adverse Benefit Determination on Appeal External Review of an Adverse Benefit Determination The Prudential Wellness Plan Page iii

5 Filing Fee for External Review Non-Benefit Claims Enrollment and Eligibility Claims Enrollment and Eligibility Claims for COBRA Coverage or COBRA-Like Coverage Other Non-Benefit Claims Appeal of an Adverse Determination of a Non-Benefit Claim Legal Action Continuing Your Coverage COBRA Coverage Employee Qualifying Events COBRA Continuation Coverage Extensions Notification How to Continue Plan Coverage Cost Coverage During the Continuation Period When COBRA Coverage Ends COBRA-Like Coverage for Qualified Adults Family and Medical Leave Act Uniformed Services Employment and Reemployment Rights Act Your Rights Prudent Actions by Plan Fiduciaries Recovery of Benefits if Payable by a Third Party Recovery of Overpayment Protecting Your Personal Health Information: HIPAA Privacy Assistance with Your Questions If You Do Not Have Access to the Prudential Benefits Center Website Service of Legal Process Glossary The Prudential Wellness Plan Page iv

6 Introduction to The Prudential Wellness Plan Please note: Throughout this SPD booklet, you will see terms whose first letters are capitalized. When you see these terms, you can check the Glossary at the back for detailed definitions and how the definitions apply to the benefits described in this SPD booklet. Prudential offers The Prudential Wellness Plan (the Plan ) to support your and your family s health and well-being. The programs offered through the Plan address areas including health, wellness, fitness, nutrition and emotional well-being. The programs are offered at no cost to you. The Prudential Wellness Plan Page 1

7 How to Contact the Prudential Benefits Center Throughout this Summary Plan Description (SPD) booklet, you will see references to the Prudential Benefits Center, which is your primary resource for information about most of your Prudential benefits. You can reach the Prudential Benefits Center online, by telephone or by mail. Online Access Through the Prudential Benefits Center website, you can: Find information about your benefits; Access benefits forms you may need; Get information on how to contact insurers and service providers; and Find links to carrier websites and online provider directories. Via the Internet Log on to to access the Prudential Benefits Center website 24 hours a day, 7 days a week. If you do not have a computer or Internet access, follow the instructions below for contacting the Prudential Benefits Center by telephone or by mail. Telephone Access You may call the Prudential Benefits Center at PRU-EASY ( ) and follow the prompts for Health and Welfare benefits. Prudential Benefits Center Representatives are available to assist you between 8 a.m. and 6 p.m., Eastern time, Monday through Friday, except on holidays. For the hearing-impaired, please contact your local relay service. Mail Access The mailing address for filing claims related to program enrollment and eligibility is: Prudential Benefits Center Claims and Appeals Management (CAM) P.O. Box 1407 Lincolnshire, IL Viewing this SPD Booklet Online This SPD booklet has been designed for ease of use when viewing it online. It includes many navigation features that allow you to locate the information you need and to access it quickly. Terms and Conditions When you use the Prudential Benefits Center website (at you are agreeing to use it under the terms and conditions prescribed by the Company. The terms and conditions are maintained on the Prudential Benefits Center website for easy reference. Or, to obtain a copy, call the Prudential Benefits Center at PRU-EASY ( ) and follow the prompts for Health and Welfare benefits. Prudential Benefits Center Representatives are available to assist you between 8 a.m. and 6 p.m., Eastern time, Monday through Friday, except on holidays. For the hearing-impaired, please contact your local relay service. The Prudential Wellness Plan Page 2

8 Joining the Plan Who Is Eligible You are eligible to participate in the programs described in this SPD booklet if you are an: Employee; or Agency Distribution Financial Professional Who Is Not Eligible You are not eligible to participate in the programs described in this SPD booklet if you are: Included in a collective bargaining unit, unless the collective bargaining agreement specifically provides for participation in the Plan An Employee of a non-participating affiliate An International Employee, except as otherwise noted A Retired Employee, except as otherwise noted An Employee classified as a part-time field force marketing assistant A temporary or occasional Employee An Agent Emeritus, Premier Retired Representative, or Retired Representative Agency Distribution Financial Professional Emeritus An individual service provider compensated through an employee leasing company, temporary employment agency or other third party agency An individual who would be treated as an Employee solely by reason of such individual being treated as either part of an affiliated service group or a leased employee under the Internal Revenue Code and regulations An independent contractor, even if the court or regulatory authority treats the individual as a regular employee Any former Employee Any student intern A person retained on a monthly fee or per diem basis An examining physician or other person rendering services solely on the basis of fees A person working under the direction of real estate management firms or other contractors An Agency Distribution Probationary Financial Professional; or Any other person who performs services for Prudential but is not treated by Prudential as an Employee for Federal tax purposes Please refer to the Plan Documents for a complete listing of the classes of Employees who are ineligible to participate in the Plan. If you would like to request a Plan Document, you should write to the Plan Administrator at the address shown in Plan Administrator on page 20. The Prudential Wellness Plan Page 3

9 Qualified Dependent Eligibility Your Qualified Dependents are also eligible for the Employee Assistance Program, Health Coaching Program, and Best Doctors Program coverage described in this SPD booklet. Your Qualified Dependents are: Your Spouse or your Domestic Partner: Your Domestic Partner: To meet the eligibility requirements of a same-sex or opposite-sex Domestic Partner under the Plan, your Domestic Partner must: Be age 18 or older Have lived with you for at least six months and remain a member of your household during the period of coverage Be and have been in a serious and committed relationship with you for at least six months Be Financially Interdependent with you Not be related to you in any way that would prohibit legal marriage (laws may vary from state to state); and Not be legally married to, or a Domestic Partner of, anyone else. Please note: For the Clinic Program only: The Clinic Program is available only to Employees and Agency Distribution Financial Professionals; Qualified Dependents are not eligible to participate in this Program. For the Best Doctors Program only: Your Parents, Parents-in-Law, Step-Parents or Step-Parents-in-Law are also eligible for coverage Your Dependent Child(ren): Please note: For the Health Coaching Program only: Dependent Children must be at least age 18 to participate. Your Dependent Children are: Your natural children under age 26 Your stepchildren under age 26 Your legally adopted children under age 26 Children under age 26 placed with you for adoption Children under age 19 who are living in your home for whom you are the legal guardian and for whom you receive no monetary compensation from a state or county agency A child living in your home for whom you are the legal guardian continues to qualify between the ages of 19 and 26 if the child: For the period over age 18 and under age 24 is a full-time student at an Educational Institution Is Substantially Dependent on you; and Participated in the Plan at the time the child attained age 19. The Prudential Wellness Plan Page 4

10 Coverage is continued without regard to whether you continue to have legal responsibility under an order of guardianship; Your unmarried grandchildren under age 19 when: Your child the parent or stepparent (who has legal custody) of the grandchild meets the definition of a Dependent Child, and is covered under the Plan Your grandchild qualifies as a Qualifying Child (as defined beginning on page 47) or Qualifying Relative (as defined beginning on page 47) under the Internal Revenue Code; and Your grandchild is living in your household or is a full-time student at an Educational Institution Your unmarried grandchild living in your home for whom you are the legal guardian (as previously described) continues to qualify between the ages of 19 and 26 if the grandchild: For the period over age 18 and under age 24 is a full-time student at an Educational Institution Is Substantially Dependent on you; and Participated in the Plan at the time the grandchild attained age 19. Coverage is continued without regard to whether: Your unmarried Dependent Child continues to have legal custody of your grandchild or The grandchild continues to live in your home. Your unmarried Dependent Children (as previously described) age 26 or older who are incapable of sustaining self-supporting employment due to a mental or physical disability, if: Such children participated in the Plan at the time they attained age 26 The children participated in a different medical program at the time they attained age 26 and remained continuously covered until the loss of that other coverage and the children became participants within 31 days of the loss of the other coverage; or At the time of your marriage, your Spouse s child was already disabled and over age 26 and such child became a participant within 31 days of the date of your marriage. For a Dependent Child meeting this definition, you may continue that child s coverage as long as your child is Substantially Dependent on you, the child remains incapacitated and unmarried and the child qualifies as a Qualifying Child (as defined beginning on page 47) or as a Qualifying Relative (as defined beginning on page 47). You will be required to furnish medical evidence of the Dependent Child s disability upon request from your medical program carrier. Any child required to be covered under either a Qualified Medical Child Support Order or a National Medical Support Notice (without regard to whether such child is a Qualifying Child or a Qualifying Relative). Coverage for a Dependent Child who reaches age 26 and is not incapable of sustaining self-supporting employment due to a mental or physical disability will be terminated at the end of the pay period during which the Dependent Child reaches age 26. The Prudential Wellness Plan Page 5

11 Your Child Age 26 or Older, a Child Living in Your Home for Whom You Are the Legal Guardian and Your Grandchild Must Be Your Qualifying Child or Your Qualifying Relative Except in the case of a child required to be covered under a Qualified Medical Child Support Order or a National Medical Support Notice, your Dependent Child age 26 or older, a Child living in your home for whom you are the legal guardian and your grandchild must, in order to satisfy the definition above, qualify and continue to qualify as either your Qualifying Child or a Qualifying Relative. Special Exception Related to Multiple Support Agreements for a Child Who Has Attained at Least Age 26 and for a Grandchild There is a multiple support agreement exception to the rules for determining whether your child who has attained age 26 or your grandchild is your Qualifying Child or Qualifying Relative for purposes of eligibility under the Wellness Plan. Under this exception, your child who has attained age 26 or your grandchild will qualify as a Qualifying Relative if such child or grandchild satisfies each of the following: No one person contributes over one-half of your child or grandchild s support Over one-half of your child s or grandchild s support for the calendar year must be received from two or more persons, each of whom could have claimed your child or grandchild as a dependent but for the fact that such person alone did not contribute over one-half of such support; and Each person who contributes over 10% of your child s or grandchild s support (other than you) files with the Internal Revenue Service Form 8332 ( Release/Revocation of a Release of Claim to Exemption ) under Section 152(e) of the Internal Revenue Code that he/she will not claim the child or grandchild as a dependent on his/her Federal income tax return for the calendar year for which you are requesting coverage. You must also file the Certification Form described below with the Prudential Benefits Center, and upon request you must submit a copy of Form 8332 to the Prudential Benefits Center. If this exception applies and the Form 8332 is signed by each person contributing over 10% to your child s or grandchild s support (other than you), your child or grandchild will be treated as your Qualifying Relative for purposes of determining your child s eligibility under the Wellness Plan. Certification Form If you intend to rely upon the multiple support exception to cover a child who has attained age 26 or a grandchild under the Wellness Plan for any calendar year, you also need to submit a separate Certification Form regarding your child s or grandchild s eligibility for this exception to the Prudential Benefits Center prior to obtaining coverage for the child or grandchild. For more information, and/or to obtain a copy of the separate Certification Form, please call the Prudential Benefits Center at PRU-EASY ( ) and follow the prompts for Health and Welfare benefits. Qualified Medical Child Support Order Federal law permits assignment of benefits to your child(ren) under the Plan through a court order referred to as a Qualified Medical Child Support Order (QMCSO). The Plan honors QMCSOs issued under state domestic law that require health benefits to be provided to a child. A QMCSO is an order or judgment from a state court served on the Company or agent for service of legal process directing the Plan Administrator to cover a child for benefits under the health care plan. The Plan will not provide benefits under a QMCSO that are not otherwise provided under the Plan to dependents. Coverage under the Plan will be extended to a child covered by a QMCSO if: The QMCSO is issued while you are eligible for coverage; and The child meets the definition of a Qualified Dependent. If a court has issued a QMCSO requiring coverage for a child under your health care program, the Prudential Benefits Center must be provided with a copy of the QMCSO. You or your family may The Prudential Wellness Plan Page 6

12 obtain, without charge, a copy of the Plan s QMCSO procedures and other information about QMCSOs from the Prudential Benefits Center by calling PRU-EASY ( ) and following the prompts for Health and Welfare benefits. Prudential Benefits Center Representatives are available to assist you between 8 a.m. and 6 p.m., Eastern time, Monday through Friday, except on holidays. For the hearing-impaired, please contact your local relay service. When You Are Eligible to Enroll You are automatically enrolled in the Plan as of your first day of employment or as a newly eligible Employee. How to Enroll Prudential automatically enrolls you for participation in the Plan as soon as you are eligible for coverage. You may enroll your Qualified Dependents who are eligible to participate in the Plan at any time prior to provision of any Plan benefits for which your Qualified Dependents are eligible. You can enroll your Qualified Dependents by visiting the Prudential Benefits Center website at or calling the Prudential Benefits Center at PRU-EASY ( ) and follow the prompts for Health and Welfare benefits. Prudential Benefits Representatives are available to assist you Monday through Friday between 8 a.m. and 6 p.m., except on holidays. For the hearing-impaired, please contact your local relay service. When Coverage Takes Effect Coverage for you will take effect as of the first day of your employment or as a newly eligible Employee. If you are not actively at work on your first day of employment, coverage will not be effective until you begin work as an active Employee. Coverage for your Qualified Dependents will take effect on the day you enroll them. Cost of Coverage Coverage for you and your Qualified Dependents is provided by Prudential at no cost to you. The Prudential Wellness Plan Page 7

13 How the Plan Works The Prudential Wellness Plan offers several programs designed to help you and your family members maintain and improve your physical and mental well-being. The programs are: Employee Assistance Program Clinic Program Health Coaching Program Best Doctors Program The Prudential Wellness Plan Page 8

14 Employee Assistance Program (EAP) Through the EAP, you and your Qualified Dependents have easy access to confidential short-term assessments, counseling and referral services for a range of personal and emotional problems. The EAP makes professional counseling available through the services of FEI Behavioral Health, Inc. (FEI). FEI has a network of family service agencies and individually-contracted providers (Affiliate Counselors) that provide top-quality, professional EAP counseling services throughout the United States. FEI and individually-contracted providers ensure that all calls remain confidential. The EAP works on a self-referral basis. When you or your Qualified Dependents need the services offered by the EAP, contact the EAP directly 24 hours a day to seek the care you need. About FEI Affiliate Counselors The EAP can refer you to an Affiliate Counselor in your community who focuses on your special needs. FEI s Affiliate Counselors can help you and/or your Qualified Dependents cope with problems that affect your or your family s physical or emotional health. All counseling is provided in a professional and confidential manner. Each FEI Affiliate Counselor has a master s or doctoral degree and is licensed and/or certified by either his or her state of practice, or by a national certifying organization in states with no licensure process. An Affiliate Counselor may be a licensed psychologist, licensed or certified social worker, EAP professional, or other trained professional. During your visit, the Affiliate Counselor will: Listen to and assess your problem Help you work out a counseling or treatment plan that fits your needs; and Refer you to resources such as further counseling, psychiatric care or medical care, if more help is necessary. Eligibility You and your enrolled Qualified Dependents are eligible to participate in the Employee Assistance Program. Covered Services FEI Affiliate Counselors are trained to deal with problems that may adversely affect your personal well-being and your ability to perform on the job, whether the issues surface at home or at work, or involve family, friends, or co-workers. While counseling cannot guarantee that a problem will be solved, it can be the first step toward a solution. EAP counseling can help you address: Family/marital/relationship conflicts Alcohol or drug abuse Depression or anxiety Loss and grief; and Job-related difficulties Coverage Limitations Prudential pays 100% of the cost for up to four (4) EAP counseling sessions each calendar year with an FEI counselor for you and each of your Qualified Dependents. An Affiliate Counselor may suggest follow-up treatment that goes beyond the scope of your EAP sessions and, if so, will help connect you with that care. The Affiliate Counselor will act as an advocate The Prudential Wellness Plan Page 9

15 throughout the referral process to community-based resources or insurance-based mental health treatment. This may include: Facilitating contact with your insurance company Assisting you in locating providers Assisting you in setting up timely appointments with providers; and Arranging with you to confirm your contact with the provider. This work of connecting you with additional assistance may count as up to one full EAP session. The Medical Program or another benefit program that covers you, if applicable, may or may not pay a portion of the cost of follow-up treatment for example, if you seek psychological counseling or treatment for alcohol or drug abuse. (See the Medical Program SPD booklet or other benefit program material provided to you for more information.) Legal Consultation and Referrals The EAP also provides legal consultation and referral assistance. Each legal consultation and referral service is counted as one (1) EAP visit (of the four (4) available to Employees and Qualified Dependents per year). One session provides an intake, referral, and consultation services with a local plan attorney, for assistance on a range of legal matters. Consultations are provided on a range of legal matters, including, but not limited to, family law, housing and real estate law, consumer law, estate, auto-related matters, document review, and simple dispute resolution. After an initial intake session, a match is made based on the specific legal matter and geographic location of the Employee and Qualified Dependents. Employees and Qualified Dependents have access to one (1) consultation at no cost with a local plan attorney for up to thirty (30) minutes, either on the telephone or in the office. If you need additional legal consultation beyond the scope of your EAP sessions, the EAP offers access to attorneys whose services you can receive at a discounted rate. Financial Consultation and Education Services Moreover, Financial Consultation and Education Services are provided through the EAP. This service provides professional consultation, information, and referrals that serve to assist Employees and Qualified Dependents on a range of financial matters, including, but not limited to, debt management assistance, house purchasing and homeowners education, and financial planning. Services are available to assist Covered Individuals on a variety of issues, including preparing a budget, dealing with tax related questions, addressing identity theft, planning for retirement, and investing in a child's education. This benefit provides one (1) telephone consultation per financial matter with a financial services representative. A consultation counts as one (1) EAP visit (of the four (4) available to employees and Qualified Dependents per year). Resources, information, and referrals for further assistance are offered, if needed. Accessing the Program The EAP is available to you and your Qualified Dependents 24 hours a day, seven days a week when you call Prudential LifeSolutions at This is your single source access number for EAP and Work/Life needs. Use prompt #1 for the EAP and use prompt #2 for Work/Life. Participants who have a telephone device for the hearing impaired may call the TTY line at Your call to Prudential LifeSolutions at will be answered by an automated voice attendant, which will offer you a series of phone prompts that will connect you with all of the Prudential LifeSolutions programs. Prompt #1 will connect you with an FEI assessment professional. He or she will assess your needs and offer you an appointment, if appropriate or requested, to see an FEI Affiliate Counselor within two working days. FEI will attempt to provide you with an appointment with a counselor located within either 20 miles or a 30-minute drive of your work location or residence. At your appointment, your counselor will assess your situation and help you develop a course of action. The Prudential Wellness Plan Page 10

16 You can access information online about your EAP benefits through: Prudential s intranet site, PRU Today. Select Quick Links and you will see a link to Prudential LifeSolutions. Click on the link and enter your IONS ID and Network password to authenticate. Finally, click on the EAP link located on the right side of the Prudential LifeSolutions home page in the third module titled, Employee Assistance Programs The EAP website (at and The Prudential Benefits Center website (at where there is a link to the EAP website. Confidentiality The EAP guarantees your confidentiality. Any contact with the EAP is your business and your business alone. FEI Affiliate Counselors will not release the names of the Employees they see, unless an Employee gives written permission to do so. Release of the information is required by state or federal law or due to a court order. The EAP only releases to Prudential the total number of people accessing EAP counseling services and aggregate information regarding such matters as primary issues for which participants seek assistance. Coordination with the Medical Program While short-term counseling with a professional counselor may be enough to address and resolve a particular problem, additional treatment may be needed, including: Inpatient or outpatient care for alcohol or drug abuse; or Professional mental health outpatient visits to a physician, licensed psychologist or clinical social worker, which may or may not be covered under the regular provisions of the Medical Program. If you are covered by the Medical Program, refer to your Medical Program SPD booklet to see what type of additional treatment is available. If you have questions about coverage, please call your Medical Program carrier s member services. If you are not covered by the Medical Program, contact your provider for more information. Cost of Coverage Coverage for you and your Qualified Dependents is provided by Prudential at no cost to you. The Prudential Wellness Plan Page 11

17 Clinic Program Prudential offers Employees an on-site Clinic Program at certain locations. The Health and Wellness staff members at our on-site clinics are licensed nurses, physicians, behavioral health specialists and other professionals. Eligibility The Clinic Program is available only to Employees and Agency Distribution Financial Professionals; Qualified Dependents are not eligible to participate in this Program. Covered Services The Clinic Program provides the following services: Emergency treatment services Health screenings, including for cholesterol, diabetes, blood pressure, body mass index and bone density Blood pressure monitoring Health Coaching Program Allergy shots (with a prescription from your physician and your allergy serum) Laboratory services (with a prescription) Flu vaccines Illness and injury assessment, treatment and referral Other preventative prescription drugs as specified by the Plan Administrator or its delegate from time to time Behavioral Health Services assessment of personal concerns, counseling, and referrals for additional services Other Services The Clinic Program also provides the following services: Business Travel Evaluation: If you are traveling on company business these additional services are available which may include: a physical examination, immunizations, health risk consultation pre-travel, lab work, health and safety advisories, emergency resources and consultations. Routine physical examinations, lab work and diagnostic tests: These additional services are available if you are a Prudential Employee grade level 7P and above and for those International Employees designated by the Company from time to time. However, such tests shall not be for the treatment, cure, or test of a known illness or disability. The Plan Administrator shall have discretion to determine the providers and locations of physical examinations. Coverage Limitations If you require regular allergy injections, assistance is available at any clinic with a physician on-site. This service is only available for maintenance. Initiation of allergy injections must begin at your doctor s office. The Health and Wellness staff requires a written prescription from your physician and your allergy serum. The Prudential Wellness Plan Page 12

18 Please note: Clinic Program benefits shall not replace or provide a substitute for primary care services, which may be covered under the Medical Program. Accessing the Program If you become ill at work or have concerns about your health, you are encouraged to visit your on-site Health and Wellness clinic. The health services staff can provide on-site illness and injury assessment, treatment and referral. All medical visits are confidential and no information about your visit is discussed outside of the clinic without your written consent. Please note: The Clinic Program is only available during regular clinic hours of operation at locations with an on-site Health and Wellness clinic. If you work in a location with an on-site clinic, contact the nurse for more information on the services available to you. Information about the clinic locations is available on Prudential s intranet site: visit My Prudential, click on the Quick Links tab, then on the Health and Wellness link and then Medical/Wellness. You can also call the Prudential Benefits Center at PRU-EASY ( ) and follow the prompts for Health and Welfare benefits. Cost of Coverage Coverage is provided by Prudential at no cost to you. The Prudential Wellness Plan Page 13

19 Health Coaching Program The WebMD Health Coaching Program is a free, telephonic service where you ll find support, guidance, and encouragement as you try to meet your health and wellness goals. Eligibility You and your enrolled Qualified Dependents are eligible to participate in the Health Coaching Program. Please note: Dependent Children must be at least age 18 to participate. Covered Services A Health Coach can give you guidance on a range of topics, including: Nutrition Exercise Stress management Tobacco cessation Weight management Strength training Preventive screening compliance Blood pressure Blood sugar Coverage Limitations The Health Coaching Program sessions include: One kickoff session (up to 30 minutes) via the telephone or in person (if you work in Newark) with a Health Coach to get an overview of the program, set initial goals and establish a relationship Three additional outbound coaching sessions throughout the calendar year An intensive tobacco cessation program that allows for support throughout the tobacco cessation process and continued follow-up after successful quit attempts (Nicotine Replacement Therapy (NRT) is provided in the form of the patch, gum, or lozenge free of charge to the participant); and Unlimited in-bound coaching sessions per calendar year. Accessing the Program It s easy to get started with a Health Coach. Here s how: All Prudential Employees, enrolled Spouses/Domestic Partners, Dependent Children (must be age 18 or older), can opt in to participate in health coaching at the end of completing the health risk assessment or by calling and self-referring into the coaching program A representative will describe the program and answer any questions. Once you are ready to start, they ll schedule your first coaching session A welcome kit will be sent to your home or address The Prudential Wellness Plan Page 14

20 At the scheduled appointment time, a Health Coach will call you. If you need to cancel or reschedule, please call at least 24 hours in advance Schedule additional coaching sessions simply by requesting one when you speak with your Health Coach, or by calling Cost of Coverage Coverage for you and your enrolled Qualified Dependents is provided by Prudential at no cost to you. The Prudential Wellness Plan Page 15

21 Best Doctors Program The Best Doctors Program is an independent third-party provider that can help when you or covered family members, including Parents, Parents-in-Law, Step-Parents, and Step-Parents-in-Law, face a medical decision. The Best Doctors Program uses physicians who are best-in-class specialists to help you confirm your diagnosis and better understand your treatment options. There is no list of qualified conditions just call if you are feeling unsure about something to do with your care. Most people who call the Best Doctors Program are trying to make a decision about their care and the Best Doctors Program will support you in doing that. The whole process takes place over the phone, so you can call from the privacy of your home. Eligibility You and your enrolled Qualified Dependents are eligible to participate in the Best Doctors Program. Please note: Your Parents, Parents-in-Law, Step-Parents, or Step-Parents-in-Law are eligible to use Best Doctors. They do not need to be enrolled, but you must call Best Doctors to access the service for them. Covered Services The Best Doctors Program offers a range of services to help you and your family members make the right medical decisions: In-Depth Medical Review Have your medical case fully reviewed by one of the world s Best Doctors with the patented InterConsultation service. You will receive a detailed report and a confidential recommendation about your diagnosis and/or treatment plan. Ask the Expert Get personalized answers to basic questions about a diagnosis or treatment options. Simply submit your questions to the Best Doctors Program and quickly receive the right guidance from an expert physician. Find a Doctor Need a pediatrician? Want the best surgeon in your area? Looking for a medical specialist? The Best Doctors Program will help you locate the right doctor one who s nearby and in your health plan. Coverage Limitations The Best Doctors Program does not service cases of mental health disorders that do not have physical ailments because there is insufficient data contained within the records to perform an informed analysis. For such cases, in-person evaluations are more appropriate and are typically handled by referral to other health resources. Additionally, the Best Doctors Program InterConsultation program does not provide consulting services for cases being covered under Workers Compensation. Other cases typically excluded are retrospective reviews for the purposes of gathering specialists opinions for medical malpractice actions. Accessing the Program Please note: You must call the Best Doctors Program to initiate services for your Parents, Parents-in-Law, Step-Parents or Step-Parents-in-law. The Best Doctors Program provides you with a Member Advocate who is available to speak with you Monday through Friday, 8 a.m. to 9 p.m., Eastern time. After these hours you can leave a message, which is generally returned the next business day. To contact a Member Advocate, call After you call, a Best Doctors Program Member Advocate will conduct an in-depth discussion with you about your medical condition, including obtaining a full health history of you and your family. After the discussion, following your written authorization, the Best Doctors Program will gather medical records concerning your present condition and diagnosis. The Prudential Wellness Plan Page 16

22 When the records are received, the Best Doctors Program clinical team will conduct a comprehensive analysis of your clinical information. The team will select the appropriate specialist(s) for your medical condition to evaluate your case, based on the most up-to-date medical thinking. Your Member Advocate will send you a report of the specialist s findings, summarized in an easy-to-read format, as well as a comprehensive Expert Report for your treating physician s reference. The Best Doctors Program will speak with you about the report s findings and then deliver the report to your treating physician, unless you do not authorize it. Throughout the process, the Member Advocate is available to answer your questions. At both six weeks and six months after you receive the report, the Member Advocate will follow up with you to see if you need additional help. Depending on the complexity of the case and the responsiveness of an individual s current physician(s) to the requests for medical records, the Best Doctors Program process takes two to eight weeks. You remain in full control of your health care decisions. The information you and your treating physician receives from the Best Doctors Program is intended to help you make informed decisions regarding your treatment. With the Best Doctors Program, you also have access to the Ask the Expert service, which provides access to service professionals to provide answers to your medical questions where no diagnostic uncertainty exists. Confidentiality You or your Qualified Dependent will need to provide the Company name and your name. You or your Qualified Dependent should also have available any information regarding the issue, including contact information for your doctor and/or health plan provider. In addition, an authorization or release will be required if you would like your information shared with your treating physician or other individuals. If you request and authorize information to be shared, or released to a third party, the Best Doctors Program will release your report to the appropriate individuals involved with your care. Cost of Coverage Coverage for you and your enrolled Qualified Dependents is provided by Prudential at no cost to you. The Prudential Wellness Plan Page 17

23 Other Important Information When Your Coverage Ends Your coverage under the Plan will end at the end of the pay period during which: Your employment with Prudential ends You no longer meet Plan eligibility requirements You present a fraudulent claim for benefits; or Prudential terminates the Plan or coverage for any program under the Plan When Qualified Dependent Coverage Ends Coverage for a Qualified Dependent under the Plan will end at the end of the pay period during which: Your employment with Prudential ends You no longer meet Plan eligibility requirements Your Qualified Dependent becomes covered as an Employee Your Qualified Dependent no longer qualifies for coverage. (See Qualified Dependent Eligibility beginning on page 4 for more information.) You present a fraudulent claim for benefits Your Qualified Dependent presents a fraudulent claim for benefits Prudential terminates the Plan or coverage for any program under the Plan; or Prudential terminates all Qualified Dependent coverage under the Plan or coverage for any program under the Plan Notification If your Qualified Dependent no longer qualifies for coverage (for example, if your Dependent Child who is not residing with you becomes an Employee or you and your Spouse become divorced), you must submit notification of this change immediately. You may call the Prudential Benefits Center at PRU-EASY ( ) and follow the prompts for Health and Welfare benefits and explain that you need to remove an ineligible dependent from coverage. Prudential Benefits Center Representatives are available to assist you between 8 a.m. and 6 p.m., Eastern time, Monday through Friday, except on holidays. For the hearing-impaired, please contact your local relay service. If You Are Disabled If you exhaust your Short Term Disability (STD) benefits, your coverage under the Plan will cease at the end of the pay period in which your STD benefits end. You may choose to continue your Plan coverage under COBRA at no cost to you (see Continuing Your Coverage beginning on page 30 for more information). If You Take a Leave of Absence If you take a paid leave of absence, your coverage under the Plan will continue automatically. If you take an unpaid leave of absence, your coverage under the Plan will continue for up to six months. At the end of six months, your coverage ends and you are eligible to elect continuation of coverage under COBRA (see Continuing Your Coverage beginning on page 30 for more information). The Prudential Wellness Plan Page 18

24 For more details on FMLA leaves of absence, see the Family and Medical Leave Act section beginning on page 34. If You Retire If you Retire, your participation in the Plan will cease at the end of the pay period in which you Retire. If you have not attained age 65, you and your Qualified Dependents are eligible to continue your participation in the Health Coaching Program and the Best Doctors Program at no cost to you, or you may choose to continue Plan coverage for you and your enrolled dependents under COBRA at no cost, up to a maximum of 18 months (shorter if you or your enrolled dependents become entitled to Medicare). (See Continuing Your Coverage beginning on page 30 for more information.) The Prudential Wellness Plan Page 19

25 Administrative Information The Prudential Wellness Plan SPD booklet is intended to describe the specific provisions and coverage options under the Plan available to eligible Employees of Prudential. In addition to knowing these provisions, you need to be aware of important administrative details, including what steps you may take if you believe that a claim has been wrongfully denied. You also need to know about your legal rights as a participant in the Plan under the Employee Retirement Income Security Act (ERISA) of 1974, as amended This booklet constitutes the Summary Plan Description of the Wellness Plan effective as of April 1, 2013, and provides important information about your rights under ERISA. This SPD booklet should in no way be considered a substitute for the Plan Document, which governs the operation of the Plan. You can access information online about your Plan benefits through Prudential s intranet site, PRU Today, or the Prudential Benefits Center website (at If you have any questions regarding The Prudential Wellness Plan SPD booklet, please call the Prudential Benefits Center at PRU-EASY ( ) and follow the prompts for Health and Welfare benefits. Prudential Benefits Center Representatives are available to assist you between 8 a.m. and 6 p.m., Eastern time, Monday through Friday, except on holidays. For the hearing-impaired, please contact your local relay service. Plan Administration and Funding Plan Name and Number Plan Name Plan Number Type of Plan Plan Administrator The Prudential Wellness Plan 504 Welfare The Prudential Wellness Plan Committee Plan Administrator The Plan Administrator for the Plan is The Prudential Wellness Plan Committee (which is responsible for administering matters under the Plan). The address for the Plan Administrator is: The Prudential Insurance Company of America Prudential Wellness Plan Committee 213 Washington Street Newark, NJ Telephone: Plan Sponsor The sponsor for the Plan described in this SPD booklet is: The Prudential Insurance Company of America Prudential Plaza 751 Broad Street Newark, NJ Telephone: A complete list of Participating Employers may be obtained by participants and Qualified Dependents upon written request to the Plan Administrator and is available for examination without charge by participants and Qualified Dependents at the Plan Administrator s office. You may make a written request to the Plan Administrator for information as to whether a particular employer participates in the Plan and, if so, the employer s address. Employer Identification Number The Company s employer identification number assigned by the Internal Revenue Service is The Prudential Wellness Plan Page 20

26 Plan Year The Plan Year is the 12-month period used for maintaining the Plan s financial records. The official Plan Year for the Plan is January 1 through December 31 of each calendar year. Funding, Payment and Claims of Plan Benefits Prudential pays the full cost of coverage under the Plan and benefits are funded through Company assets. Administrators The following lists the third party administrators providing benefits under the Program. ASO refers to the contract that provides administrative services, but no guarantee, by the provider. Prudential Wellness Program Provider Provider Roles* The Employee Assistance Program Clinic Program Best Doctors Program FEI Behavioral Health West Lake Park Drive Milwaukee, WI Prudential Health and Wellness Staff 213 Washington Street Newark, NJ Best Doctors, Inc. One Boston Place, 3 rd floor Boston, MA ASO N/A ASO Health Coaching Program WebMD 2701 NW Vaughn Street, Suite700 Portland, OR ASO * For program enrollment and eligibility claims, the Prudential Benefits Center is the Claims Administrator and the Wellness Plan Committee is the Claims Fiduciary. Plan Amendment or Termination The Company has reserved the right, subject to applicable law, to amend, modify, suspend or terminate the Plan, including but not limited to the benefits discussed in this SPD booklet, in whole or in part. Any such action would be taken in writing and maintained with the records of the Program. Program amendment, modification, suspension or termination may be made for any reason, and at any time. Such amendments may be made retroactive if necessary to meet statutory requirements or for any other appropriate reason. The official Plan document for The Prudential Wellness Plan describes the procedures for amending or terminating the Plan and who may make amendments. Assignment of Benefits The programs summarized in The Prudential Wellness Plan SPD booklet are used exclusively to provide benefits to you, and in some cases, to your eligible Qualified Dependents. You cannot assign ownership of your Plan benefits. National Medical Support Notice The Plan Administrator will consider any National Medical Support Notice as a QMCSO. Upon receipt of such a Notice (issued with respect to the child of a participant who is such child s non-custodial parent) that meets the requirements of a QMCSO, the Plan Administrator will inform the issuing state agency of the benefits available to the child and all procedures necessary to enroll the child in such benefits. The custodial parent will also be notified of available coverage and will be provided any forms or documents necessary to enroll the child in such coverage. The non-custodial parent will be liable to the Plan to pay for all Employee contributions, if applicable, required under the Plan for the The Prudential Wellness Plan Page 21

27 enrollment of the child. The Plan will not provide benefits under a National Medical Support Notice that are not otherwise provided under the Plan to Dependent Children. Claims, Claims Appeals and External Claims Review Procedures You, or any person you choose to represent you, must follow the claims, claims appeals and external claims review procedures outlined below before taking action in any other forum regarding a claim under the Plan. The Plan Administrator, the Wellness Plan Committee, or its delegate will process any writing that is identified as a claim for benefits (either by the claimant or, if the writing is not specific, by the Plan Administrator) under the claims, claims appeals and claims review procedures outlined below. If your claim is not identified as a claim for benefits, the Plan Administrator or its delegate will treat your writing or communication as a claim under the Non-Benefit Claims procedures beginning on page 28. Enrollment and eligibility claims will be identified as Non-Benefit Claims and will be processed under the Non-Benefit Claims procedures beginning on page 28 unless they are part of a claim for health care benefits. For example, if you file a claim for benefits that is denied because you are not eligible to participate in the Plan, your claim will be considered a claim for benefits and will follow the procedures outlined in the Claim for Benefits section below. For all enrollment and eligibility claims, the Prudential Benefits Center is the Claims Administrator and the Wellness Plan Committee is the Claims Fiduciary. If your claim for benefits is denied, it will be considered an Adverse Benefit Determination. An Adverse Benefit Determination is any denial, reduction, or termination of a benefit, or a failure to provide or make a payment. You have the right to appeal any Adverse Benefit Determination under the procedures described below. A claim shall be considered approved only if approval is communicated to you in writing. If you do not receive a response to any claim within the applicable time period, you may proceed with an appeal under the procedures described below. If your appeal is denied, you may be eligible for a second level of appeal or for an external review of your claim for benefits under the procedures described below. Claim for Benefits Making a Claim for a Benefit When you apply for or request a benefit in any manner, this will generally constitute a claim. The information below will tell you exactly how to file for a benefit under The Prudential Wellness Plan. There are times when a phone call to the Prudential Benefits Center, the Claims Administrator, questioning why you are not covered or how to apply for a benefit can constitute a claim. The Prudential Benefits Center can always give you more information on how to request or apply for a benefit. You can reach the Prudential Benefits Center by calling PRU-EASY ( ) and following the prompts for Health and Welfare benefits. What Information to Include in a Claim Your claim should state your name, address, the specific basis for your claim and any additional materials you wish to present. Note that claims may be submitted in writing or can be filed by phone. Call the Prudential Benefits Center, the Claims Administrator, at PRU-EASY ( ) for more information and follow the prompts for Health and Welfare benefits. Benefits under each ERISA-governed plan will be paid only if the Prudential Wellness Plan Committee, the Claims Fiduciary, decides in its sole discretion that the claimant is entitled to them. When to File a Claim The best time to file a claim for benefits is as soon as possible after the circumstances creating the claim take place. You are entitled to file a claim for benefits to which you believe you are entitled, up to one year from the date your claim arose. A claim will be presumed to have arisen when you have actual or constructive notice of the events giving rise to the claim. The Prudential Wellness Plan Page 22

28 Urgent Care Claims Notice of a decision on your claim for benefits (whether adverse or not) must be provided no later than 72 hours, after receipt of your claim by the Prudential Benefits Center, the Claims Administrator. If you fail to provide sufficient information to determine whether benefits are covered or payable under the Plan, you must be notified within 24 hours of the information necessary to complete your claim. You will have at least 48 hours to provide the information. The Claims Administrator will then notify you of your benefit determination no later than 48 hours, from the earlier of the receipt of any additional information you provide or the end of the period afforded to you to provide the specified additional information. An Urgent Care Claim means any health claim for care or treatment with respect to which the application of the time periods for making non-urgent care determinations could seriously jeopardize your life or health or your ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of your claim. The Claims Administrator determines whether a claim is an Urgent Care Claim on the basis of information provided by you or your representative. You must provide specific information regarding whether and what medical circumstances exist that may give rise to a need for expedited processing as an Urgent Care Claim. Any claim that a physician with knowledge of your medical condition determines is a claim involving urgent care will be treated as an Urgent Care Claim. Concurrent Care Claims If an ongoing course of treatment has been approved, any reduction or termination of such course of treatment before the end of the period will be considered an Adverse Benefit Determination. The Claims Administrator will notify you sufficiently in advance of the reduction or termination to allow you to request an appeal. If you have been notified that an ongoing course of treatment must be reduced or terminated, your request to extend the course of treatment that is an Urgent Care Claim must be decided as soon as possible based on the medical circumstances and you must be notified of the decision within 24 hours after receipt of your claim by the Claims Administrator, provided that your claim is made at least 24 hours before the expiration of the prescribed period of time or number of treatments. If your request is not made at least 24 hours before your treatment expires, your request shall be treated as an Urgent Care Claim and decided as soon as possible but not later than 72 hours after receipt of your request, unless it does not involve urgent care. If your request does not involve urgent care, it shall be treated as a Pre-Service Claim or a Post-Service Claim. Pre-Service Claims Notice of a decision on your claim for benefits (whether adverse or not) must be provided by the Prudential Benefits Center, the Claims Administrator, no later than 15 days after receipt of your claim. If the Claims Administrator determines that, due to matters beyond the control of the Plan, an extension of time is necessary, you must be provided with notice of the extension before the end of the initial 15-day period. The notice must explain the circumstances requiring the extension and the date by which the Claims Administrator expects to render a decision. In no event will the extension exceed an additional 15 days from the end of the initial period. The notice will describe any required information needed and you will have at least 45 days from receipt of the notice to provide this information. If you have submitted additional information to the Claims Administrator, you will receive notice of the decision within 15 days of receipt of the information. If you fail to follow the Plan s procedures for filing a Pre-Service Claim, you will be notified (either orally or in writing) and given the proper procedures to be followed. This notice will be provided to you no later than five days (24 hours in the case of a failure to file an Urgent Care Claim) following the failure. This notice requirement will apply only if you, or your authorized representative, communicate to the Claims Administrator the following information: your name, the specific medical condition or symptom for which you are seeking treatment and the specific treatment and service or product for which you are requesting approval. A Pre-Service Claim means any health claim which requires approval of the benefit before obtaining care. The Prudential Wellness Plan Page 23

29 Post-Service Claims A Post-Service Claim means any health claim that is not a Pre-Service, Concurrent Care or Urgent Care Claim. Notice of an Adverse Benefit Determination must be provided by the Prudential Benefits Center, the Claims Administrator, no later than 30 days after receipt of your claim. If the Claims Administrator determines that, due to matters beyond the control of the Plan, an extension of time is necessary, you will be provided with notice of the extension before the end of the initial 30-day period. The notice will explain the circumstances requiring the extension and the date by which the Claims Administrator expects to render a decision. In no event will the extension exceed an additional 15 days from the end of the initial period. The notice will describe any required information needed and you will have at least 45 days from receipt of the notice to provide this information. If the period of time is extended due to your failure to submit information necessary to decide your claim, the period for making the determination will be suspended from the date on which the notice is sent to you until you respond to the request for additional information. If you have submitted additional information to the Claims Administrator, you will receive notice of the decision within 15 days of receipt of the information. Notice of Adverse Benefit Determination The written notice 1 of your Adverse Benefit Determination (that is, any denial, reduction or termination of a benefit, or a failure to provide or make a payment) will include the following: The specific reason(s) for the Adverse Benefit Determination References to the specific program provisions of the Plan on which the Adverse Benefit Determination is based A description of any additional material or information needed to complete or support your claim and an explanation of why that material or information is necessary A description of or a copy of the Plan s appeal and external claims review procedures, the time limits under the procedures, and a statement of your right to bring a civil action under Internal Revenue Code Section 502(a) of ERISA, after you have completed all mandatory appeals and any available external claims review under the program A copy of any internal rule, guideline, protocol or other similar criterion relied upon (if any) in making the Adverse Benefit Determination or a statement that a copy of any internal rule, guideline, protocol or other similar criterion relied upon (if any) in making the Adverse Benefit Determination will be provided to you free of charge upon request If the Adverse Benefit Determination was based on a medical necessity, experimental treatment or similar exclusion or limit, the notice must include either an explanation of the scientific/clinical judgment for the determination, how the terms of the Plan apply to your medical circumstances or a statement that an explanation will be provided to you free of charge upon request; and If the Adverse Benefit Determination concerns an Urgent Care Claim, a description of the expedited appeal and external review process applicable to such a claim. No notice is required to be provided to you for a favorable benefit determination, except for an Urgent Care Claim or a Pre-Service Claim. Appeal of an Adverse Benefit Determination How to File a Claim for Benefits If you have followed the above procedures and you have received an Adverse Benefit Determination, you may appeal the decision. Normally, your request must be in writing, but if it is an Urgent Care 1 In the case of an Urgent Care Claim, notice may be provided orally, provided that written notice is provided no later than three days after the oral notification. The Prudential Wellness Plan Page 24

30 Claim, the request may be oral. If you desire to appeal, you must ask The Prudential Wellness Plan Committee or its delegate to review your Adverse Benefit Determination within 180 days after you receive a notification of an Adverse Benefit Determination. You will have the opportunity to submit written comments, documents, records and other information relating to your claim. You can mail your appeal to the address noted on your Adverse Benefit Determination notice. Access to Records Upon your request and free of charge, you will be provided reasonable access to and copies of all documents, records and other information relevant to your claim. When your claim is reviewed, all comments, documents, records and other information that you submitted will be taken into account without regard to whether this information was considered in your initial benefit determination. Appeals Procedures The following appeals procedures will be provided: Your appeal will not give deference to the initial Adverse Benefit Determination on your claim and will be conducted by a Fiduciary of the Plan, as determined by the Plan Administrator or its delegate, who is neither the individual who made your initial Adverse Benefit Determination, nor that individual s subordinate. In deciding an appeal of any Adverse Benefit Determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational or not medically necessary or appropriate, the Fiduciary conducting the review shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. The medical or vocational experts whose advice was obtained on behalf of the Plan in connection with your previous Adverse Benefit Determination shall be identified, upon your request, without regard to whether the advice was relied upon in making your previous Adverse Benefit Determination. The health care professional engaged for purposes of a consultation, shall be an individual who is neither an individual who was consulted in connection with your previous Adverse Benefit Determination, nor the subordinate of any such individual. You will be provided, free of charge, with any new or additional evidence considered, relied upon, or generated by the Plan (or at the direction of the Plan or its delegate) in connection with your claim. The evidence will be provided as soon as possible and sufficiently in advance of the date on which the notice of the final internal Adverse Benefit Determination is required to be provided to you. You also will be provided, before issuance of a final internal Adverse Benefit Determination based upon a new or additional rationale, with the rationale. That rationale will be provided as soon as possible and sufficiently in advance of the date on which the notice of the final internal Adverse Benefit Determination is required to be provided to you. For any Urgent Care Claim, all necessary information, including the Claims Fiduciary s decision on your appeal, will be transmitted between the Claims Fiduciary and you or your representative by telephone, facsimile, or other available similarly expeditious method. Time for Determination You or your representative will be notified of the Claims Fiduciary s decision on your appeal within the following time periods: In the case of an Urgent Care Claim, as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of your request for appeal (if two levels of appeal are available, both decisions must be provided within 72 hours after receipt of your internal request for appeal) The Prudential Wellness Plan Page 25

31 In the case of a Pre-Service Claim, other than an Urgent Care Claim, within a reasonable period of time appropriate to the medical circumstances, but not later than 30 days after receipt of your request for appeal and not later than 15 days, if two levels of appeal are applicable; or In the case of a Post-Service Claim, within a reasonable period of time, but not later than 60 days after receipt of your request for appeal and not later than 30 days, if two levels of appeal are applicable The above periods of time shall begin at the time your appeal is filed in accordance with the Plan s procedures, without regard to whether all the information necessary to make a benefit determination accompanies your filing. Notice of Adverse Benefit Determination on Appeal Your notice of an Adverse Benefit Determination on your appeal will include the following: The specific reason or reasons for the Adverse Benefit Determination Reference to the specific provisions of the Plan on which the Adverse Benefit Determination is based A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information that are relevant to your claim for benefits; A description of any mandatory or voluntary appeal procedures offered under the program, a description of the external review procedures, your right to obtain information about such procedures and a statement of your right to bring an action under Internal Revenue Code Section 502(a) of ERISA, after you have completed all mandatory appeals and any external claims review available under the program; A copy of any internal rule, guideline, protocol or other similar criterion relied upon (if any) in making the Adverse Benefit Determination on your appeal or a statement that a copy of any internal rule, guideline, protocol or other similar criterion relied upon (if any) in making the Adverse Benefit Determination on your appeal will be provided to you or your representative free of charge upon request; If your Adverse Benefit Determination on appeal was based on a medical necessity, experimental treatment or similar exclusion or limit, the notice must include either an explanation of the scientific/clinical judgment for the determination, how the terms of the Plan apply to your medical circumstances, or a statement that an explanation will be provided to you free of charge upon request; The following statement: You and your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your state insurance regulatory agency ; and You will be advised in your notice of Adverse Benefit Determination whether your claim may be considered under a second level of mandatory appeal or under a voluntary level of appeal. Upon completion of any available second level of mandatory appeal, or of a voluntary appeal (if you choose to exercise any right to a voluntary appeal), your claim may be eligible for an external review, as discussed below. External Review of an Adverse Benefit Determination If you receive an Adverse Benefit Determination after you have completed all mandatory levels of appeal, you may be eligible to request an external review. In addition, if you receive an Adverse Benefit Determination on your initial Urgent Care Claim and you qualify for expedited external review, you may be eligible to simultaneously file a request for an external review at the same time as your The Prudential Wellness Plan Page 26

32 request for an internal appeal is being processed. You are only eligible for an external review if your claim for benefits involved medical judgment or involved a rescission of coverage, which is a cancellation or discontinuance of medical coverage that is effective retroactively and that is not due to failure to timely pay required premium contributions towards the cost of coverage. In your request for external review, you must provide all forms and information needed to process the review. Under applicable law, the procedures to follow for external review are described below. The Plan is considered a self-insured program. Under the Plan, a claim is subject to either a standard external review or an expedited external review, as follows: Standard External Review. Most claims are subject to a standard external review under the following procedures: Filing Due Date. Your request for a standard external review must be filed within four months of the date you receive a notice of an Adverse Benefit Determination in the case of a simultaneous internal appeal and external review or the date you receive a final internal Adverse Benefit Determination in the case of all other requests for external review. If there is no corresponding date that is four months after receipt of the notice, the filing due date is the first day of the fifth month following receipt of the notice. If the filing due date falls on a Saturday, Sunday or Federal holiday, the filing due date is extended to the next day that is not a Saturday, Sunday or Federal holiday Preliminary Review by the Plan Administrator, or its Delegate or by an Independent Review Organization ( IRO ) if medical judgment is the basis for your request for review. Within five business days of the date of receipt of the request for external review, the Plan Administrator, or its delegate, or the IRO will determine whether your claim is eligible for external review Initial Notification. Within one day thereafter, you will be notified in writing as follows: If your request is complete but your claim is not eligible for external review, the reasons why your claim is ineligible. You will be provided contact information for the Employee Benefit Security Administration of the U.S. Department of Labor; or If your request is not complete, the notice will describe the materials needed to make your request complete. You will have until the later of 48 hours following receipt of the notification or the filing deadline to complete your request Assignment to IRO. If your request is complete, you are a participant and the claim is eligible for external review, the Administrative Committee, or its delegate, will assign it to an IRO. The Plan will provide the IRO the documents and any information the Plan considered in making the final internal Adverse Benefit Determination (or the Adverse Benefit Determination in the case of simultaneous appeal and external review) on your claim New Information. You will be entitled to submit any new information to the IRO and the IRO will forward that information to the Plan. Upon receipt of the new information, the Administrative Committee, or its delegate, may reconsider its Adverse Benefit Determination and reverse it by deciding to provide coverage or payment. If the Administrative Committee, or its delegate, reverses its decision, it will notify you and the IRO, which will then terminate the external review Decision and Notice. The IRO will consider the documents and information provided and provide written notice of the final external review decision to you and to the Plan within 45 days after the IRO receives the request for the external review; and The Prudential Wellness Plan Page 27

33 Expedited External Review Procedures. You are entitled to an expedited external review if either: You received a final internal Adverse Benefit Determination, and you have a medical condition where the time frame for completion of a standard external review would seriously jeopardize your life or health, or your ability to regain maximum function, or if the final internal Adverse Benefit Determination concerns the availability of care; or You received an Adverse Benefit Determination on your initial claim that involves a medical condition for which the time frame for completion of an expedited internal appeal would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function and you desire to file a request for an expedited external review simultaneously with your filing for an expedited internal appeal. An expedited external review is subject to the same procedures as a standard external review, as described above, but modified as follows: Preliminary Review. The determination of whether your request meets the requirements for an external review and whether your claim qualifies for expedited treatment will be made immediately upon receipt of your request for an expedited external review. The initial notification to you regarding whether your request meets the standards for an expedited external review will be sent to you immediately Assignment to IRO. If the Plan Administrator, or its delegate, determines that your request is eligible for an expedited external review, the Plan will assign an IRO and provide all necessary documents and information considered in its Adverse Benefit Determination to the IRO electronically or by telephone or facsimile or by any other available expeditious method (if medical judgment is the basis for your request for review, the IRO will determine the eligibility of the request); and Notice. The IRO will provide notice of its final external review decision as expeditiously as your medical condition or circumstances require, but in no event more, not more than 72 hours after the IRO receives the request for an expedited external review. If the initial notice of the final external review decision is not provided in writing, the IRO will provide written confirmation of the final external review decision to you and the Plan within 48 hours after the date of providing the initial notice. Filing Fee for External Review If you request an external review, you may be required to pay to the Plan up to a $25.00 filing fee for each request. The fee will be waived if the Plan Administrator, or its delegate, determines that payment of the filing fee would impose an undue financial hardship upon you. The maximum limit on filing fees to be paid by you for any Plan Year (assuming you file three or more appeals in one calendar year) is $ The filing fee will be refunded if the Adverse Benefit Determination or Final Adverse Benefit Determination is reversed through the external review. The $25.00 filing fee and the $75.00 maximum Plan Year limit on filing fees may be adjusted from time to time as determined by the Plan Administrator, or its delegate, in its sole discretion, subject to any limitations imposed by applicable law. Non-Benefit Claims Enrollment and Eligibility Claims If you have questions regarding a program enrollment or eligibility claim (for example if you dispute eligibility for the Plan), please contact the Prudential Benefits Center You may contact the Prudential Benefits Center by calling PRU-EASY ( ) and following the prompts for Health and Welfare benefits. Prudential Benefits Center Representatives are available to assist you between 8 a.m. and 6 p.m., Eastern time, Monday through Friday, except on holidays. For the hearing-impaired, please contact your local relay service. The Prudential Wellness Plan Page 28

34 If you and the Prudential Benefits Center are not able to resolve your issue, you may submit a written notice with the specific basis for your claim and send it to the following address: Prudential Benefits Center Claims and Appeals Management (CAM) P.O. Box 1407 Lincolnshire, IL Your claim will be considered as soon as practicable following its receipt. Notice of an adverse determination shall be provided no later than 90 days after receipt of the claim. If the Prudential Benefits Center determines that special circumstances require an extension of time for processing the claim, written notice shall be furnished prior to the end of the 90-day period. Such extension shall not exceed 180 days after the date your claim was received. If you have followed the above procedures and you receive an adverse determination, you may appeal the decision by following the steps described under Appeal of an Adverse Determination of a Non-Benefit Claim on page 30. There is no right to an external review of the decision on appeal of a Non-Benefit Claim. For all enrollment and eligibility claims, the Prudential Benefits Center is the Claims Administrator and the Wellness Plan Committee is the Claims Fiduciary. Enrollment and Eligibility Claims for COBRA Coverage or COBRA-Like Coverage If you have questions regarding a program enrollment or eligibility claim (for example, if you dispute eligibility for continued Plan coverage) for COBRA coverage or for COBRA-like coverage (continued coverage for Domestic Partners that is similar to COBRA coverage [see COBRA-Like Coverage for Qualified Adults on page 34 for more information]), please contact the Prudential Benefits Center, the COBRA administrator by calling PRU-EASY ( ) and following the prompts for Health and Welfare benefits. Prudential Benefits Center Representatives are available to assist you between 8 a.m. and 6 p.m., Eastern time, Monday through Friday, except on holidays. For the hearing-impaired, please contact your local relay service. Your claim will be considered as soon as practicable following its receipt. Notice of an adverse determination shall be provided no later than 90 days after receipt of the claim. If the Prudential Benefits Center determines that special circumstances require an extension of time for processing the claim, written notice shall be furnished prior to the end of the 90-day period. Such extension shall not exceed 180 days after the date your claim was received. If you have followed the above procedures and you receive an adverse determination, you may appeal the decision by following the steps described under Appeal of an Adverse Determination of a Non-Benefit Claim on page 30. There is no right to an external review of a decision on a Non-Benefit Claim. For all enrollment and eligibility claims for COBRA coverage or for COBRA-like coverage, the Prudential Benefits Center is the Claims Administrator and the Wellness Plan Committee is the Claims Fiduciary. Other Non-Benefit Claims To make a claim under The Prudential Wellness Plan, other than for a claim for benefits (see Claim for Benefits beginning on page 22) or for enrollment and eligibility claims (see Enrollment and Eligibility Claims beginning on page 28), you must send your request in writing to: The Prudential Insurance Company of America Prudential Wellness Plan Committee c/o Health and Wellness Department 213 Washington Street Newark, NJ Your claim should state your name, address, the specific basis for your claim and any additional materials you wish to present. The Prudential Wellness Plan Page 29

35 Your claim will be considered by The Prudential Wellness Plan Committee or its delegate as soon as practicable following its receipt. Notice of an adverse determination shall be provided no later than 90 days after receipt of the claim. If the Plan Administrator, or its delegate, determines that special circumstances require an extension of time for processing the claim, written notice shall be furnished prior to the end of the 90-day period. Such extension shall not exceed 180 days after the date your claim was received. Appeal of an Adverse Determination of a Non-Benefit Claim If you have followed the above procedures and you receive an adverse determination, you may appeal the decision by making a request in writing within 60 days after you receive notice of the adverse determination. Appeals must be sent to the Wellness Plan Committee or its delegate, at the address in the Other Non-Benefit Claims section beginning on page 29. Your appeal will be considered by the Wellness Plan Committee or its delegate as soon as practicable. Notice of an adverse determination of your appeal shall be provided no later than 60 days after receipt of the appeal. If the Wellness Plan Committee or its delegate determines that special circumstances require an extension of time for processing the appeal, written notice shall be furnished prior to the end of the 60-day period. Such extension shall not exceed 120 days after the date your request to appeal your adverse determination was received. The Wellness Plan Committee, as Plan Administrator, may appoint itself, one or more of its number, or any other person or persons whether or not connected with Prudential to review a claim. The ultimate decision of the Wellness Plan Committee or its delegate shall be final and binding. Claims under the Program will be granted only if the Plan Fiduciary or its delegate decides, in its sole discretion, that they should be granted. There is no right to an external review of a decision on appeal of a Non-Benefit Claim. For more information, you may call the Prudential Benefits Center at PRU-EASY ( ) and follow the prompts for Health and Welfare benefits. Legal Action All the facts and circumstances of your case will be thoroughly reviewed. If you have completed all of the above claims, claims appeals and claims review procedures (see Claims, Claims Appeals and External Claims Review Procedures beginning on page 22) and your appeal and external review (if applicable) are given an Adverse Benefit Determination, you have the right to bring legal action if you believe the adverse determination is incorrect and was decided in an arbitrary and capricious manner. Any suit or legal action initiated by you must be brought by the earlier of either (i) one year following a final decision on your claim, including any appeal or external review, or (ii) two years measured from the date your claim arose (except that this two-year limitation period will be suspended during the appeal and review of a claim under the Plan s Claims, Claims Appeals and External Claims Review Procedures and except to the extent any policy or contract of an insurer provides a longer period of time to institute any suit or legal action). This time period for bringing a suit or legal action applies in all forums. Continuing Your Coverage COBRA Coverage Under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (commonly known as COBRA), you, your Spouse, and your Dependent Child(ren) may elect to temporarily continue coverage under the Plan if coverage ends because of a Qualifying Event as described below. To be eligible for continued Plan coverage, you must be enrolled in one or more programs under the Plan when the coverage would otherwise end as a result of the Qualifying Event. In addition to you, your Spouse, and any Dependent Child(ren) covered at the time of a Qualifying Event, any child who is born to you, adopted or placed for adoption with you during COBRA coverage is also eligible for coverage. If you choose to continue coverage through COBRA, you are not required to make contributions for this coverage; however, you are required to make a timely COBRA election. The Prudential Wellness Plan Page 30

36 Employee Qualifying Events If your coverage terminates due to any of the reasons in the table below, you, your enrolled Spouse and/or your enrolled Dependent Child(ren) may continue Plan coverage under COBRA. Coverage can be continued as follows: If Coverage Stops Because: You leave the Company (for any reason other than gross misconduct) The Maximum Continuation Period Is: 18 months for you, your enrolled Spouse and/or enrolled Dependent Child(ren) You change to an ineligible Employee status You reduce your hours of employment; or You fail to return from a leave of absence. You and your Spouse divorce or legally separate Your Dependent Children no longer qualify You become entitled to Medicare and elect Medicare as your primary coverage* 36 months for your enrolled Spouse 36 months for each enrolled Dependent Child 36 months for your enrolled Spouse and/or Dependent Child(ren) You die 36 months for your Enrolled Spouse and/or Dependent Child(ren) *For COBRA purposes, entitlement to Medicare means being enrolled in Medicare Parts A and/or B. Please note: If you choose to disenroll a Qualified Dependent from coverage at any time, including during the Annual Enrollment Period, the Qualified Dependent will not experience a Qualifying Event or become eligible to elect COBRA continuation coverage. COBRA Continuation Coverage Extensions If your coverage under the Program ends because you ended your employment or reduced your hours of employment, you, your Spouse and/or your Dependent Child(ren) may extend the 18-month COBRA continuation period if you experience certain events, as described in the table that follows. Event Your Spouse and/or Dependent Child(ren) experience a second Qualifying Event within the original 18-month period. You and/or your Spouse and/or Dependent Child(ren) are disabled* (as determined by the Social Security Administration) on the following dates: The date your employment ends; The date you experience a reduction in work hours so that Program coverage terminates; or At any time during the first 60 days of COBRA continuation coverage due to such event. Who May Extend COBRA Your enrolled Spouse and/or enrolled Dependent Child(ren) You, your enrolled Spouse and/or your enrolled Dependent Child(ren) (whether or not disabled) Period of Extension May extend the COBRA continuation period for up to an additional 18 months, for a total of up to 36 months from the original Qualifying Event. May extend COBRA continuation coverage for up to an additional 11 months (for a total of 29 months from the original Qualifying Event). IMPORTANT NOTE: If a second Qualifying Event occurs at any time during this 29-month disability continuation period, then your Spouse and/or Dependent Child(ren) (whether or not disabled) may further extend COBRA coverage for seven more months, for a total of up to 36 months from the end of your employment with Prudential or reduction in hours of employment. Table and footnote continue on page 32. The Prudential Wellness Plan Page 31

37 Event Who May Extend COBRA Period of Extension You became entitled to Medicare coverage while employed and then, within 18 months, have a termination of employment or reduction in hours that causes a loss of coverage. Your Spouse and/or Dependent Child(ren) May elect COBRA continuation for up to the longer of: 18 months from the termination of employment or reduction in hours; or 36 months from the date you first became entitled to Medicare. This remains valid even if your Medicare entitlement was not considered a Qualifying Event for your Spouse and/or Dependent Child(ren) because their coverage was not lost or reduced. * To qualify for this disability extension, you and/or your Spouse and/or Dependent Child(ren) must both notify the Prudential Benefits Center and provide the Prudential Benefits Center with a copy of the Notice of Award letter from the Social Security Administration before the end of the original 18-month COBRA period and within 60 days of the latest of: The date of the disability determination by the Social Security Administration The date the Qualifying Event occurred The date coverage was lost as a result of the Qualifying Event; or The date you and/or your Spouse and/or Dependent Child(ren) were informed, either through your SPD booklet or your initial COBRA notice, of your responsibility to notify the Prudential Benefits Center and the procedures for providing such notice to the Prudential Benefits Center. Please note that, in the case of a disability, the process of applying for and receiving the determination from the Social Security Administration may take up to or more than six months. Therefore, you must apply as soon as possible in order to forward the Social Security disability determination before the end of the above deadlines. If these steps are not followed, the right to extend coverage from up to 18 months to up to 29 months will be lost. An Example of Extended COBRA Continuation Coverage Let s assume your employment ended because you left the Company for a reason other than gross misconduct. Your Dependent Child elects COBRA continuation coverage and, after six months, reaches the age limit for Dependent Child eligibility and ceases to qualify as a Dependent under the Program. Because ceasing to qualify as a Dependent is a second Qualifying Event that occurred within the original 18-month period, your Dependent Child may elect to extend the COBRA continuation period for up to an additional 18 months from the end of the first 18-month period of the original Qualifying Event. Therefore, your Dependent Child would be eligible to receive a total of up to 36 months of COBRA continuation coverage, as long as you or your Dependent Child notifies the Prudential Benefits Center within 60 days of the later of the Qualifying Event or the date that benefits would be terminated under the Program as a result of the Qualifying Event. Notification To qualify for COBRA continuation upon legal separation, divorce or loss of a child s Dependent Child status under the Program, you must submit notification of this change via the Prudential Benefits Center website (at or call the Prudential Benefits Center at PRU-EASY ( ), within 60 days of the Qualifying Event or the date that benefits would be terminated under the Program as a result of the Qualifying Event. Prudential Benefits Center Representatives are available to assist you between 8 a.m. and 6 p.m., Eastern time, Monday through Friday, except on holidays. For the hearing-impaired, please contact your local relay service. Alternately, your Spouse or Dependent Child(ren) may contact the Prudential Benefits Center to notify of a change in status. The Prudential Wellness Plan Page 32

38 You and/or your Spouse and/or Dependent Child(ren) then will be provided with a notice of your rights to continue your Plan coverage and instructions. (See How to Continue Plan Coverage in the section that follows for more information.) Individuals already on COBRA continuation must notify the Prudential Benefits Center within these deadlines of a legal separation, divorce or loss of a child s Dependent status that would extend the period of COBRA coverage for you, your Spouse or Dependent Child(ren). For other Qualifying Events, you will be provided with instructions for continuing your Plan coverage. In the event of your death, the Company will notify your Spouse and/or your Dependent Child(ren) regarding how to continue Plan coverage. How to Continue Plan Coverage When you, your Spouse and/or your Dependent Child(ren) become eligible for coverage under the COBRA continuation provision, the Prudential Benefits Center will send you a notice of the right to continue coverage. To elect continuation of coverage, you must notify the Prudential Benefits Center within 60 days after the later of the following dates: The date on the Qualifying Event notification; or The date Plan coverage ends. If coverage under the Plan is changed for active Employees, the same changes will apply to individuals on COBRA continuation. Your Spouse and/or your Dependent Child(ren) also may change their coverage elections during Annual Enrollment or at other times under the Program to the same extent that similarly situated Qualified Adults who are non-cobra Employees may do so. Cost There is no cost for continuing Wellness Plan coverage through COBRA. However, you and your dependents must be enrolled at the time you experience a Qualifying Event. Coverage During the Continuation Period If coverage under the Plan is changed for active Employees, the same changes will apply to individuals on COBRA continuation. Your Spouse and/or your Dependent Child(ren) also may change their coverage elections at other times under the Plan to the same extent that similarly situated non-cobra Employees may do so. When COBRA Coverage Ends COBRA continuation of Plan coverage for any person will end when the first of the following occurs: The applicable continuation period ends After the date COBRA is elected, you, your Spouse and/or your Dependent Child(ren) first become covered (as an Employee or otherwise) under another health care plan not offered by the Company that does not contain an exclusion or limitation affecting the person s preexisting condition, or the other plan s preexisting condition limit or exclusion does not apply. This does not apply to your Spouse and/or your Dependent Child(ren) who do not become covered under another health care plan After the date COBRA is elected, you, your Spouse and/or your Dependent Child(ren) first become entitled to Medicare. For COBRA purposes, entitlement to Medicare means being enrolled in Medicare Parts A and/or B. This does not apply to your Spouse and/or your Dependent Child(ren) who are not entitled to Medicare In the case of an extended coverage period due to disability, there has been a final determination under the Social Security Act that you, your Spouse and/or your Dependent Child(ren) are no longer disabled. In such a case, the COBRA coverage ceases for all individuals who were entitled to the 11-month extension as a result of the disability on the first day of the month that begins more than The Prudential Wellness Plan Page 33

39 30 days after the final determination is issued, unless a second Qualifying Event has occurred during the first 18 months For newborns and children adopted by or placed for adoption with you during your COBRA continuation period, the date your COBRA continuation period ends unless a second Qualifying Event has occurred; or The Company terminates all wellness program coverage for all Employees. If you or your Qualified Dependent no longer qualifies for COBRA coverage (for example, if you and/or your Spouse and/or your Dependent Child(ren) become covered under another health care plan), you must submit notification of this change by calling the Prudential Benefits Center at PRU-EASY ( ) and following the prompts for Health and Welfare benefits. COBRA-Like Coverage for Qualified Adults While COBRA coverage applies only to your Spouse and your Dependent Children, Prudential will make available (within a specified time frame) continued Plan coverage similar to COBRA coverage for Qualified Adults (a Domestic Partner) for a defined period of time if: Your Domestic Partner no longer meets the eligibility requirements under the Plan You no longer meet the eligibility requirements under the Plan Your employment with Prudential ends; or You die To be eligible for COBRA-like coverage, your Domestic Partner must be enrolled in the Plan at the time of the Qualifying Event listed above. You are not required to make contributions to continue this coverage; however, you are required to make an election for COBRA-like coverage. If you die while continuing your own coverage under COBRA, your Domestic Partner may continue the COBRA-like coverage for the remainder of the coverage period. Family and Medical Leave Act All Employees who have at least one year of service and have worked at least 1,000 hours (excluding any unpaid leave, any disability absences and any designated FMLA absences during that period) during the 12 months prior to commencing a leave are eligible for unpaid leave under the Federal Family and Medical Leave Act of 1993 (FMLA). Eligible Employees may take an unpaid leave of absence, up to 12 weeks, under the following circumstances: For incapacity due to pregnancy, prenatal medical care or child birth To care for the Employee s child (as defined by applicable law) after birth, or placement for adoption or foster care For placement with the Employee of a son or daughter (as defined by applicable law) for adoption or foster care To care for the Employee s Spouse, son, daughter or parent (as defined by applicable law) with a serious health condition For a serious health condition that makes the Employee unable to perform the functions of the Employee s job; or For qualifying exigencies when the Employee s Spouse, child or parent (as defined by applicable law) is on active duty in a foreign country or called to active duty status and deployed to a foreign country by the National Guard, Reserves, or as a retired member of the regular armed services or reserves exigency leave). Qualifying exigencies may include attending certain military events, The Prudential Wellness Plan Page 34

40 arranging for alternative childcare, addressing certain financial and legal arrangements, attending counseling sessions and attending post-deployment reintegration briefings. The Company also provides a special leave entitlement that permits eligible Employees to take up to 26 weeks of leave to care for a covered service member during a single 12-month period. A covered service member is a: Current member of the Armed Forces, including a member of the National Guard or Reserves, who has a serious injury or illness incurred in the line of active duty (or had a serious injury or illness that existed before the beginning of the member s active duty and was aggravated by service in the line of duty while on active duty in the Armed Forces) that may render the service member medically unfit to perform his/her duties and for which the service member is either undergoing medical treatment, recuperation or therapy, is in outpatient status or is on the temporary disability retired list; or Veteran who is undergoing medical treatment, recuperation or therapy, for a serious injury or illness that was incurred in the line of active duty (or had a serious injury or illness that existed before the beginning of the member s active duty and was aggravated by service in the line of duty while on active duty in the Armed Forces) and who was a member of the Armed Forces, including a member of the National Guard or Reserves, at any time during the period of five years preceding the date on which the veteran undergoes that medical treatment, recuperation or therapy. The 26-week leave available to eligible Employees to care for a family member (child, parent, Spouse or next of kin) who has incurred an illness or injury in active military duty is not in addition to the 12-week leave allotment available for other types of FMLA leave. Thus, if an Employee takes leave for any other reason permitted by the FMLA, the leave will be deducted from the 26-week allotment during that year. Certain state statutes may provide additional leave rights and coverage. For complete information regarding your FMLA leave rights and responsibilities, as well as your family and medical leave rights and obligations in the specific state in which you work, contact your local Human Resources Consultant or refer to the Human Resources Policies Lotus Notes database under the Quick Links tab on Prudential s intranet site, PRU Today. During your FMLA leave, if you are covered under The Prudential Wellness Plan, the Company will continue your coverage for up to six months under the same terms and conditions as you would have received if you had not taken the leave. Benefits will automatically continue during an FMLA leave. When you return to work after your leave of absence, your coverage will be reinstated automatically upon your return to work. If you are planning to take an FMLA leave of absence, and have questions about your Wellness Plan benefits during your absence, call the Prudential Benefits Center at PRU-EASY ( ) and follow the prompts for Health and Welfare benefits. Prudential Benefits Center Representatives are available to assist you between 8 a.m. and 6 p.m., Eastern time, Monday through Friday, except on holidays. For the hearing-impaired, please contact your local relay service. If you are planning to take an FMLA leave of absence and have questions regarding FMLA, call the FMLA Services Unit at PRU-EASY ( ) and follow the prompts for Disability and Leaves. Uniformed Services Employment and Reemployment Rights Act The Uniformed Services Employment and Reemployment Rights Act (USERRA) provides certain protections and reemployment rights to employees who are absent from work due to service in the Armed Forces, Army National Guard or Air National Guard (collectively, uniformed service ). If, as a result of service in the uniformed service, you take a leave from work, generally, your absence will be designated as an authorized, unpaid leave. During this leave, you will be treated in the same manner as other Employees who are on an unpaid leave. The Prudential Wellness Plan Page 35

41 In addition, if your service qualifies for protection under USERRA, and lasts less than 31 days, Prudential automatically will extend any existing medical, dental, vision and wellness coverage offered under the Plan for you and your Dependents (other than Parents, Parents-in-Law, Step-Parents and Step-Parents-in-Law), for 30 days beyond the date on which your leave commences, provided that you continue to pay the Employee contributions required by the Plan, if applicable. If your leave extends beyond 31 days, you, your Spouse and/or your Dependent Children may elect to continue any existing medical, dental, vision and wellness coverage offered under the plan for 24 months, or until you fail to return to employment, whichever period is less, provided that you pay the full cost of the coverage at non-employee rates, if applicable. Please note: Only a Spouse and Dependent Children are considered dependents under USERRA and therefore would be eligible for benefits under USERRA. All other Qualified Dependents under the Plan are not eligible for benefits under USERRA. However, a Domestic Partner may be entitled to COBRA-like continuation coverage under the Plan. Your Rights As a participant in the Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974, as amended (ERISA). ERISA provides that all ERISAgoverned Program participants shall be entitled to: Receive information about the Program, including: Examine, without charge, at the Plan Administrator s office and at other specified locations such as worksites, all documents governing the Program. This includes insurance contracts, 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 Employee Benefits Security Administration; and Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Program, including insurance contracts, collective bargaining agreements and copies of the latest annual report (Form 5500 Series) and the updated Summary Plan Description. The Plan Administrator may make reasonable charges for the copies. Continue Plan coverage: Continue Plan coverage if there is a loss of coverage under the Plan as a result of a Qualifying Event. You or your Qualified Dependents may have to pay for such coverage. Review this Prudential Wellness Plan SPD booklet and the documents governing the Plan on the rules governing your COBRA continuation coverage rights. (See Continuing Your Coverage beginning on page 30 for more information.) Enforce your rights: If your claim for a benefit is denied or ignored, in whole or in part, you have the 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 may take to enforce the above rights. For instance: If you request a copy of the Plan Documents or the latest annual report from the Plan Administrator 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 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, after you complete (or if your claim is ignored, have attempted to The Prudential Wellness Plan Page 36

42 complete) all of the claims and appeals procedures. (See Claims, Claims Appeals and External Claims Review Procedures beginning on page 22.) If you disagree with the Plan s decision or lack thereof concerning the qualified status of a Qualified Medical Child Support Order (QMCSO), you may file suit in Federal court, after you complete all of the claims and appeals procedures (See Assignment of Benefits on page 21, Qualified Medical Child Support Order beginning on page 6, and Claims, Claims Appeals and External Claims Review Procedures beginning on page 22 for more information); and If it should happen that Plan Fiduciaries misuse the Program 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 after you complete all of the claims and appeals procedures. (See Claims, Claims Appeals and External Claims Review Procedures beginning on page 22.) 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. Prudent Actions by Plan Fiduciaries In addition to creating rights for the Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefits plans. The people who operate the Plan, called Fiduciaries of the Program, have a duty to do so prudently and in the interests of all participants and Qualified Dependents. No one, including your employer, your union (if applicable), or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA. Recovery of Benefits if Payable by a Third Party Benefits otherwise payable to you (i.e., the participant Employee or your covered Qualified Dependent) under the Plan will be reduced to the extent that payment is made directly or indirectly to you or on your behalf, or to your assignee, by any third party or its insurer. This could occur as the result of the actual or alleged wrongful act or omission of any third party (e.g., an automobile accident) or a payment made or to be paid from your own no-fault and automobile insurance policy(ies) (i.e., uninsured motorist coverage, underinsured motorist coverage, medical payments coverage [ Med Pay ], no-fault coverage and/or personal injury coverage [ PIP ]). If the Plan provides benefits to you, or your covered Qualified Dependent, that are later determined to be the legal responsibility of another person, company, or insurer, the Plan has a first priority right to recover these payments from you or your covered Qualified Dependent in full and regardless of whether you have been made whole. If you make a claim for benefits before you receive payment from any third party or its insurer, you are considered by the Plan to have agreed that any recovery you receive from any third party or its insurer will be used to repay the Plan for its payments on your behalf. The Plan s right to recovery applies whether: You receive payment due to a legal judgment, an arbitration award, a compromise settlement or any other arrangement Any third party or its insurer admits liability for the payment; or The expenses the Plan paid are separately identified or otherwise itemized in the payment made to you by the third party or its insurer. You should know that an assignment of your claim to any third party does not exempt you from your responsibility for repayment. Any attorney fees or costs incurred by you are not the responsibility of the Plan and are to be paid solely by you. The Prudential Wellness Plan Page 37

43 You Must Give Notice. Within ten days of institution of any legal proceedings on your behalf against any third party or its insurer for recovery of any amount that otherwise would be payable to the Plan under this section, you must notify the Plan of the legal proceedings, including the names of the parties, the name and location of the forum, the status of the case, the names, addresses and phone numbers of all attorneys and the case number. You must also, within 30 days prior to any settlement of any legal proceedings against the third party or its insurer, notify the Plan of the terms of the proposed settlement. The Program s Legal Rights. By accepting payment from the Plan benefits, you are deemed to have agreed that the Program may take all action necessary or appropriate in the discretion of the Company or its delegate to enforce its rights under this section. Such action includes, but is not limited to: Subrogation: The Plan is subrogated to (stands in the place of) all rights of recovery you or your covered Qualified Dependent have against any third party or insurer for all or any portion of the benefits provided or to be provided by the Plan. Restitution: In addition, if you or a covered Qualified Dependent receives any payment from any third party or insurer, the Plan has the right to obtain restitution (including a right of reimbursement) from you, your attorney or any third party, for all amounts the Plan has paid and will pay, up to and including the full amount you receive. Constructive Trust: The Plan has a right to obtain a legal order that you, your attorney, or anyone acting on your behalf is considered to hold any amount you recover from any third party or insurer for benefits provided or to be provided under the Plan in a constructive trust for the benefit of the Plan. Lien Rights: Further, the Plan will automatically have an equitable lien to the extent of benefits paid by the Plan for which any third party is liable. The lien shall be imposed upon any recovery whether by settlement, judgment or otherwise, including from any insurance coverage, for which the Plan paid benefits. The lien may be enforced against any party who possesses funds or proceeds representing the amount of benefits paid by the Plan including, but not limited to you or your representative or agent; any third party or insurer; and/or any other source possessing funds representing the amount of benefits paid by the Program. Stay or Other Equitable Relief: The Plan has a right to obtain a stay of any legal proceedings brought by you or your covered Qualified Dependent against any third party and to enjoin you and your assignees from adjudicating the matter. It also may obtain a preliminary or permanent injunction, a declaration of rights, or specific performance against you, your attorney or any assignee of either of them. Moreover, the Plan has the right to obtain any other appropriate equitable relief to redress any violation of the Plan or enforce the terms of the Plan. The Plan also has the right to obtain such judicial relief against you or any assignee as may be available under state law, including a claim for breach of contract. Applicability to All Settlements and Judgments. The Plan shall be entitled to full recovery regardless of whether any liability for payment is admitted by any third party or insurer and regardless of whether the settlement or judgment received by you identifies the benefits the Plan provided or purports to allocate any portion of such settlement or judgment to the payment of expenses other than Wellness Benefits. The Plan is entitled to recover from any and all settlements or judgments, even those designated as pain and suffering, non-economic damages, and/or general damages. Cooperation. You and your covered Qualified Dependents are prohibited from prejudicing the Plan s subrogation or recovery interest or prejudicing the Plan s ability to enforce the terms of this Plan provision. This includes, but is not limited to, refraining from making any settlement or recovery that attempts to reduce or exclude any portion of the cost of any benefits provided by the Plan. The Plan has the right to conduct an investigation regarding the injury, illness, or condition for which benefits were provided under the Plan to identify any third party or insurer responsible for the payment of all or any portion of those benefits. The Plan reserves the right to notify the third party and his or her agents of its lien. Agents include, but are not limited to, insurance companies and attorneys. The Prudential Wellness Plan Page 38

44 Written Agreement to Repay. The Plan may require you to sign a written agreement to repay any amounts received by you in the event you recover such amounts from any third party or its insurer, including establishing a trust or lien on any monies you are to receive. Failure to Comply. If you fail to timely provide the notice required under this section or refuse to execute any agreement, if requested to do so, no further benefits will be paid on your behalf under the Plan until the Plan either recovers all amounts you are required to repay or offsets against your future benefits payable under the Plan, any payments made by the Plan that it was unable to recover. The Plan has the right to conduct an investigation regarding the injury, illness or condition for which benefits were provided under the Plan to identify any third party or insurer responsible for the payment of all of any portion of those benefits. The Plan reserves the right to notify the third party and its agents of its lien. In the sole discretion of the Company, or its delegate, any action by you to frustrate or avoid recovery by the Plan, as required by this section may be grounds for termination of all your benefits under the Plan. Interpretation. In the event that any claim is made that any part of this subrogation and right of recovery provision is ambiguous or questions arise concerning the meaning or intent of any of its terms, the Company, or its delegate has the sole authority and discretion to resolve all disputes regarding the interpretation of this provision. Jurisdiction. By accepting benefits (whether the payment of such benefits is made to you or your covered Qualified Dependent or made on your behalf or your Qualified Dependent s behalf to any provider) from the Plan, you and your covered Qualified Dependent agree that any court proceeding with respect to this provision may be brought in any court of competent jurisdiction as the Plan may elect. By accepting such benefits, you and your covered Qualified Dependent are deemed to agree to submit to each such jurisdiction, waiving whatever rights you and your covered Qualified Dependent may have by reason of his or her present or future domicile. Recovery of Overpayment If the Plan provides benefits to you or a covered Qualified Dependent that are later determined to be in excess of the covered amounts, the Plan has the right to recover these payments from you. You should know that an assignment of your claim to any third party does not exempt you from your responsibility for repayment of overpayments. Protecting Your Personal Health Information: HIPAA Privacy Prudential s health care programs are subject to the privacy regulations issued by the Department of Health and Human Services (HHS) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) ( Privacy Regulations ) and will protect your confidential health information. The Plan maintains a HIPAA Notice of Privacy Practices, which describes your rights and the Plan s responsibilities under the Privacy Regulations. To obtain a copy of the notice, visit the Prudential Benefits Center website (at If you do not have access to a computer or the Internet or you need more information, you may contact the Prudential Benefits Center by calling PRU-EASY ( ) and following the prompts for Health and Welfare benefits. The Privacy Regulations were enacted to guarantee participants new rights and protection against the misuse or disclosure of their personal health information. The regulations require most health plans to provide notice of how personal health information may be used and what rights you have regarding this information. This notice must be provided before using or disclosing your health information to carry out treatment, payment or health care operations. The protection extends to information in any form, including electronic and paper records and spoken words. If you feel that your privacy protection rights have been violated, you can file formal complaints against the health care plan with HHS. For more information about Privacy Regulations, visit the HHS website (at Assistance with Your Questions If you have any questions about The Prudential Wellness Plan, you should contact the Prudential Benefits Center. If you have any questions about this statement or about your rights under ERISA, or if The Prudential Wellness Plan Page 39

45 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 contact: Division of Technical Assistance and Inquiries Employee Benefits Security Administration U.S. Department of Labor 200 Constitution Avenue, N.W. Washington, DC You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration at If You Do Not Have Access to the Prudential Benefits Center Website Throughout this SPD booklet there are references to accessing the Prudential Benefits Center website (at If you do not have access to a computer or the Internet or if you need more information, you may call the Prudential Benefits Center at PRU-EASY ( ) and follow the prompts for Health and Welfare benefits. Service of Legal Process Most questions about the Wellness programs may be resolved by calling the Prudential Benefits Center at PRU-EASY ( ) and following the prompts for Health and Welfare benefits, or by completing the claims and appeals process. (See Claims, Claims Appeals and External Claims Review Procedures beginning on page 22 for more information about this process.) However, if, after you have completed all of the claims and appeals procedures described in this Prudential Wellness Plan SPD booklet, you feel you need to take legal action to resolve a question governing your benefits or your claim, then you may contact the agent for service of legal process in a timely manner at the following address: The Prudential Insurance Company of America Vice President, Health and Wellness 213 Washington Street Newark, NJ Telephone: Legal papers may also be served in a timely manner on the Wellness Plan Administrative Committee or the respective Plan Trustee, if any. Any suit or legal action must be brought by you no later than one year following a final decision on your claim for benefits. The Prudential Wellness Plan Page 40

46 Glossary In this section, you will find definitions for some of the terms used in this SPD booklet. If you need more help understanding a certain term, call Prudential Benefits Center at PRU-EASY ( ) and follow the prompts for Health and Welfare benefits. Prudential Benefits Center Representatives are available to assist you between 8 a.m. and 6 p.m., Eastern time, Monday through Friday, except on holidays. For the hearing-impaired, please contact your local relay service. Adverse Benefit Determination An Adverse Benefit Determination is any denial, reduction or termination of a benefit, or a failure to provide or make a payment. You have the right to appeal any Adverse Benefit Determination under the claims and appeals procedures described in this SPD booklet. Agency Distribution Financial Professional An Agency Distribution Financial Professional is a full-time life insurance salesman as defined under Internal Revenue Code Section 3121(d)(3)(B) and the regulations prescribed thereunder, including an associate under any of the following contracts: Senior Life Representative, Agency Distribution Financial Professional Agreement or Career Special Agent. Agency Distribution Financial Professional Associate An Agency Distribution Financial Professional Associate is a common-law Employee participating in a two-year developmental program within Agency Distribution. Claims Administrator The entity designated to handle the requests for payment of benefits under the various plans and programs. In some instances, this entity may also be designated to handle appeals for denied benefits. The Claims Administrator for the Plan is the Plan Administrator or its delegate. Please note that the Claims Administrator for Program enrollment and eligibility claims is the Prudential Benefits Center and the Wellness Plan Committee is the Claims Fiduciary. The Prudential Benefits Center is the Claims Administrator for COBRA enrollment and eligibility claims and the Wellness Plan Committee is the Claims Fiduciary for COBRA. Claims Fiduciary The Fiduciary for all actions involving the payment of benefits under an ERISA plan. The Claims Fiduciary for the Plan is the Wellness Plan Committee. The Plan Administrator or its delegate is also the Claims Fiduciary for the Plan and COBRA, including for Program enrollment, eligibility and Non-Benefit Claims. COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985, as amended) The Federal law under which you and/or your covered Qualified Dependent(s) may be able to extend your medical, dental and vision coverage and/or your participation in the Health Care Reimbursement Account, Limited Purpose Health Care Reimbursement Account and Prudential Wellness Plan after the time such coverage or participation normally would end. Company The Prudential Insurance Company of America. Concurrent Care Claim A Concurrent Care Claim means any health claim that is for an ongoing course of treatment. Cost Cost of benefits or coverages refers to the charges determined by Prudential, using the best tools available, to estimate the total amount that will be expended for your benefits during the year. If the program is self-insured (rather than provided through an actual insurance policy with a premium), the actual expenditures for the year may be higher or lower than the determined charge, depending on the year. The Prudential Wellness Plan Page 41

47 Any amount charged to a participant will be based solely on the original estimated charge, not the actual expenditures. Depending on the benefit, this Cost may be borne by the participant directly; by Prudential directly or indirectly from a Plan fund, such as a Contractual Special Reserve (CSR), established with contributions from Prudential; or by a combination of these sources. Dependent Child(ren) Your Dependent Children are: Your natural children under age 26; Your adopted children under age 26; Children under age 26 placed with you for adoption; Children under age 19 who are living in your home for whom you are the legal guardian and for whom you receive no monetary compensation from a state or county agency; A child living in your home for whom you are the legal guardian continues to qualify between the ages of 19 and 26 if the child: For the period between the ages of 19 and 24 is a full-time student at an Educational Institution; Is Substantially Dependent on you; and Participated in the Plan at the time the child attained age 19. Coverage is continued without regard to whether you continue to have legal responsibility under an order of guardianship; Your stepchildren under age 26; and Your unmarried grandchildren under age 19 when: Your child the parent or stepparent (who has legal custody) of the grandchild meets the definition of a Dependent Child, and is covered under the Plan: Your grandchild qualifies as a Qualifying Child (as defined beginning on page 47) or Qualifying Relative (as defined beginning on page 47) under the Internal Revenue Code; and Your grandchild is living in your household or is a full-time student at an Educational Institution; Your unmarried grandchild living in your home for whom you are the legal guardian (as previously described) continues to qualify between the ages of 19 and 26 if the grandchild: For the period between the ages of 19 and 24 is a full-time student at an Educational Institution; Is Substantially Dependent on you; and Participated in the Plan at the time the grandchild attained age 19. Coverage is continued without regard to whether: Your unmarried Dependent Child continues to have legal custody of your grandchild; or The grandchild continues to live in your home. The Prudential Wellness Plan Page 42

48 Your unmarried Dependent Children (as previously described) age 26 or older who are incapable of sustaining self-supporting employment due to a mental or physical disability, if: Such children participated in the Plan at the time they attained age 26; The children participated in a different medical program at the time they attained age 26 and remained continuously covered until the loss of that other coverage and the children became participants within 31 days of the loss of the other coverage; or At the time of your marriage, your Spouse s child was already disabled and over age 26 and such child became a participant within 31 days of the date of your marriage. For a Dependent Child meeting this definition, you may continue that child s coverage as long as your child is Substantially Dependent on you, the child remains incapacitated and unmarried and the child qualifies as a Qualifying Child (as defined beginning on page 47) or as a Qualifying Relative (as defined beginning on page 47). You will be required to furnish medical evidence of the Dependent Child s disability upon request from your medical program carrier. Any child required to be covered under either a Qualified Medical Child Support Order or a National Medical Support Notice (without regard to whether such child is a Qualifying Child or a Qualifying Relative). Coverage for a Dependent Child who reaches age 26 and is not incapable of sustaining self-supporting employment due to a mental or physical disability will be terminated at the end of the pay period during which the Dependent Child reaches age 26. Except in the case of a child required to be covered under a Qualified Medical Child Support Order or a National Medical Support Notice, your Dependent Child age 26 or older, a Child living in your home for whom you are the legal guardian and your grandchild must, in order to satisfy the definition above, qualify and continue to qualify as either your Qualifying Child or a Qualifying Relative. See the definitions of Qualifying Child beginning on page 47 and Qualifying Relative beginning on page 47 for more information. Domestic Partner To meet the eligibility requirements of a same-sex or opposite-sex Domestic Partner under the Program, your Domestic Partner must: Be age 18 or older; Have lived with you for at least six months and remain a member of your household during the period of coverage; Be and have been in a serious and committed relationship with you for at least six months; Be Financially Interdependent with you; Not be related to you in any way that would prohibit legal marriage (laws may vary from state to state); Not be legally married to, or a Domestic Partner of, anyone else; and Not otherwise be eligible for coverage under the Plan (for example, as a Prudential Employee, Retiree or Dependent Child). The Prudential Wellness Plan Page 43

49 Educational Institution An institution which maintains a regular faculty and curriculum, including primary and secondary schools, colleges, universities and technical and mechanical schools. The term does not include non-educational institutions, on-the-job-training schools and correspondence schools. Employee Generally, any person who is categorized as an Employee on the books and records of the Company or any affiliate, or is compensated as an Agency Distribution Financial Professional by the Company or any affiliate, will be considered an Employee for the purposes of this Program. The term Employee never includes any individual who is associated with the Company or any affiliate as: An Agent Emeritus, Premier Retired Representative or Retired Representative; An independent contractor (other than an Agency Distribution Financial Professional); A service provider compensated through an employee leasing company, temporary employment agency or other third-party agency; An individual who would be treated as an employee solely by reason of such individual being treated as either part of an affiliated service group or a leased employee under the Internal Revenue Code and regulations; or Any other individual who performs services for the Company or an affiliate but is not treated as an Employee for Federal tax purposes at the time the individual renders services. Please refer to the Plan Documents for a complete listing of the classes of Employees who are ineligible to participate in the Plan. See also Who Is Not Eligible on page 3. ERISA ERISA is the Employee Retirement Income Security Act of 1974, as amended, which is the Federal statute governing private pension and welfare plans. Fiduciary One who exercises discretion on behalf of an ERISA plan and its participants in the management or disposition of ERISA plan assets or ERISA plan administration, or one who renders investment advice for a fee with respect to ERISA plan assets. Financially Interdependent A requirement for Domestic Partner eligibility, Financially Interdependent means that you and your Domestic Partner share the cost of food and housing. You both do not have to contribute equally or jointly for each of these expenses as long as you are both responsible for such costs. Independent Review Organization (IRO) An Independent Review Organization (IRO) is an organization that conducts independent external medical reviews of adverse health care benefit determinations and final adverse benefit determinations. Under Federal law, IROs must be accredited by URAC, formerly known as the Utilization Review Accreditation Commission, or a similar nationally recognized accrediting organization. The IRO will review the claim in accordance with evidence-based medical guidelines to provide an impartial determination that is consistent with recognized medical standards. Internal Revenue Code The Internal Revenue Code of 1986, as amended, is the Federal statute governing taxes and certain benefits plans and programs. International Employee An employee or retiree who is not or was not an Employee of a Participating Employer operating in the United States of America and is or was compensated for services rendered for an Affiliate in The Prudential Wellness Plan Page 44

50 currency other than currency of the United States of America and paid from a payroll system other than that used by a Participating Employer to pay Employees in the United States of America. Medical Program A component of The Prudential Welfare Benefits Plan which helps pay the cost of medical services for Employees (and eligible Qualified Dependents) of the Prudential Insurance Company of America and its Participating Affiliates. Non-Benefit Claim A Non-Benefit Claim means any claim other than a claim for benefits. Unless they are part of a claim for health care benefits, enrollment and eligibility claims are considered Non-Benefit Claims. Parent, Parent-in-Law, Step-Parent or Step-Parent-in-Law A person who is the Parent, Parent-in-Law, Step-Parent or Step-Parent-in-Law of the Employee. Participating Affiliate or Participating Employer The Company and its Affiliated Companies that elect to participate in the benefits plan or program. Plan Administrator Generally, the Plan Administrator is the entity that has overall responsibility for administration of a benefits plan or program, including interpreting the Plan Documents, establishing procedures, record keeping and filing all necessary reports regarding the benefits plan or program and publishing and distributing communication materials. The Plan Administrator is the Wellness Plan Committee. Plan Document(s) The Plan Documents are the written documents describing all the benefits and limitations pertaining to a particular Employee benefits plan or program. Plan Sponsor The Plan Sponsor is the employer establishing a benefits plan or program for its eligible participants and/or beneficiaries. The Prudential Insurance Company of America is the Plan Sponsor for the Program described in this SPD booklet. Plan Year The Plan Year is the period for all plan administration accounting and reporting. The Plan Year for each of the benefits plans or programs is the calendar year, beginning each January 1 and ending the following December 31. Post-Service Claim A Post-Service Claim means any health claim that is not a Pre-Service, Concurrent Care or Urgent Care Claim. Pre-65 Retiree A Pre-65 Retiree is a Retiree who is under age 65 and at the termination of employment: Has ten or more years of Vesting Service (as defined under The Prudential Merged Retirement Plan, and including any additional periods of Vesting Service granted under The Prudential Welfare Benefits Plan for the purpose of eligibility); and Either: Attained the first of the month coinciding with or next following his or her 55th birthday; or Is considered a retired participant under the terms of The Prudential Traditional Retirement Plan (a component of The Prudential Merged Retirement Plan). The Prudential Wellness Plan Page 45

51 Pre-Service Claim A Pre-Service Claim means any health claim that requires approval of the benefit before obtaining care. Prudential Prudential is The Prudential Insurance Company of America and its Participating Affiliates. Prudential s Group Health Plans The Medical, Dental, Vision, Long Term Care, Global Medical and Global Dental Programs under The Prudential Welfare Benefits Plan as well as the Medical Access Plan, the Executive Medical Access Plan and The Prudential Wellness Plan. The Prudential Merged Retirement Plan As restated effective January 1, 2006, and amended through December 31, 2008, The Prudential Merged Retirement Plan is a defined benefit pension plan. It was first adopted in 1941, and has been amended over the years. The Prudential Merged Retirement Plan consists of The Prudential Traditional Retirement Plan Document Component One (referred to as the traditional pension formula ), the Prudential Securities Incorporated Cash Balance Pension Plan Document Component Two (the PSI Plan ), and the Prudential Cash Balance Pension Plan Document Component Three (referred to as the cash balance formula ). The Prudential Welfare Benefits Plan An Employee benefits plan established by the Company in order to provide various health and welfare benefits for participants. Benefits provided under the Plan include Medical, Dental, Vision, Disability, Life Insurance, Long Term Care and LegalCare. Qualified Adult A Qualified Adult is a person who meets certain eligibility requirements for a program and is not your Spouse. A Qualified Adult is a Domestic Partner (as defined in this Glossary). Qualified Dependents Qualified Dependents are: Your Spouse or your Domestic Partner; Your Parent, Parent-in-Law, Step-Parent or Step-Parent-in-Law (the Parents and Step-Parents of only the Employee are eligible for the Best Doctors Program); and Your Dependent Children (as defined in this Glossary). Qualified Medical Child Support Order (QMCSO) A QMCSO is a court judgment, decree or order meeting certain requirements that permits assignment of benefits to your child(ren) under the Health Care Reimbursement Account and the Limited Purpose Health Care Reimbursement Account under The Prudential Flexible Benefits Plan, the Medical Access Plan, the Executive Medical Access Plan, The Prudential Wellness Plan and the following programs under The Prudential Welfare Benefits Plan: Medical Program Dental Program Vision Care Insurance Program Global Medical Program; and Global Dental Program The Prudential Wellness Plan Page 46

52 Qualifying Child A Qualifying Child is defined under Internal Revenue Code Section 152(a)(l) without regard to whether your child has dependents. Subject to Internal Revenue Code Section 152, your child who has attained age 26, a child living in your home for whom you are the legal guardian, and/or your grandchild will be considered your Qualifying Child if such child or grandchild is an individual who: Is your child or stepchild or a descendant of your child or stepchild; and Has the same principal place of abode as you do for more than one-half of the calendar year; Is younger than you and: In the case of a child living in your home for whom you are the legal guardian or a grandchild, has not attained age 19 as of the close of the calendar year; In the case of a child living in your home for whom you are the legal guardian or a grandchild, is a student who has not attained age 26 as of the close of the calendar year; or In the case of a child living in your home for whom you are the legal guardian or a grandchild or child who has attained at least age 26, is permanently and totally disabled at any time during the calendar year; and Has not provided more than one-half of his/her own support for the calendar year; and Has not filed a joint return with his/her spouse for the calendar year. If you and one or more other individuals could otherwise claim your child or grandchild as a Qualifying Child the following applies: If both you and the other individual are parents of a child, your child would be your Qualifying Child if you are the parent with whom your child resided the longest; or if your child resided with both parents for the same amount of time, if you are the parent with the highest adjusted gross income; If only one of the individuals is the parent of your child, your child would be the Qualifying Child of that parent; If the parents of the child or grandchild can claim the child as a Qualifying Child for purposes of Internal Revenue Code Section 152, but do not do so, the child or grandchild may be claimed by you as your Qualifying Child only if you have adjusted gross income higher than any other person who could claim the child or grandchild; or If neither parent could claim the child or grandchild, the child will be your Qualifying Child only if you are the individual with the highest adjusted gross income. Qualifying Event A Qualifying Event is an event that allows you to continue certain health care coverage under COBRA (the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended). This event can be the loss of a job, death, divorce or a Qualified Dependent reaching the age of ineligibility. Specific Qualifying Events are described in this SPD booklet. Qualifying Relative Under the Plan, a Qualifying Relative is defined under Internal Revenue Code Section 152(a)(2) without regard to the requirement that the child have gross income less than the exemption amount or whether a child living in your home for whom you are the legal guardian, a child age 26 or older or the grandchild has dependents. Subject to Internal Revenue Code Section 152, a child living in your home for whom you are the legal guardian, your child age 26 or over or your grandchild would be your Qualifying Relative if such child or grandchild is generally an individual: The Prudential Wellness Plan Page 47

53 Who is related to you as follows: your child or a descendant of your child, son, daughter, stepson, stepdaughter, son-in-law, daughter-in-law, brother-in-law, sister-in-law or any person (other than your Spouse) who, for that calendar year, has the same principal place of abode as you do and is a member of your household; For whom you provide over one-half the individual s support for the calendar tear or otherwise satisfy the special exception related to multiple support agreements under Internal Revenue Code Section 152(d)(3) as described under the definition of Dependent Child(ren) above; and Who is not your Qualifying Child or any other individual s Qualifying Child for the calendar year. Retire/Retiree Terms used to indicate that you have become eligible for benefits under the Prudential Retiree Medical Program, the Retiree Dental Program, the Retiree Life Insurance Program and the Retiree Vision Program. You may be eligible for these benefits at the time your employment with Prudential ends if you meet the terms of the Prudential Welfare Benefits Plan, including if you: Have ten or more years of Vesting Service (as defined under The Prudential Merged Retirement Plan, and including any additional periods of Vesting Service granted under The Prudential Welfare Benefits Plan for the purpose of eligibility); and Either: Have attained the first of the month coinciding with or next following your 55th birthday; or Are considered a Retired Participant under the terms of The Prudential Traditional Retirement Plan (a component of The Prudential Merged Retirement Plan). Spouse Spouse, whether capitalized or lowercase, shall mean the person to whom a participant is legally married. A person can qualify as a participant s Spouse only if such person can qualify as the participant s Spouse under the terms of the Defense of Marriage Act, P.L (September 21, 1996); accordingly, the term Spouse is limited to a person of the opposite sex who is a husband or a wife pursuant to a marriage that constitutes a legal union between one man and one woman as husband and wife, and a person of the same sex as a participant shall not be treated as the participant s Spouse. Substantially Dependent To be considered Substantially Dependent, your Dependent Children and/or Parents, Parents-in-Law, Step-Parents or Step-Parents-in-Laws must receive more than one-half of their maintenance and support from you or your Spouse, as defined by the Internal Revenue Code Section 152. Urgent Care Claim An Urgent Care Claim means any health claim for care or treatment with respect to which the application of the time periods for making non-urgent care determinations could seriously jeopardize your life or health or your ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of your claim. U.S. Expatriate An Employee who is a citizen of the U.S. or a non-u.s. citizen hired by a U.S. Affiliate and paid from the U.S. payroll who is on assignment to perform services outside of the U.S. for a period that is expected to exceed three months, and who is designated by the SVP (as defined in The Prudential Welfare Benefits Plan) or his or her delegate as a U.S. Expatriate. The Prudential Wellness Plan Page 48

54 Vesting Service Vesting Service is determined in accordance with The Prudential Merged Retirement Plan (and including any additional periods of Vesting Service granted under The Prudential Welfare Benefits Plan for the purpose of eligibility). Generally, your Vesting Service includes time worked and certain approved or authorized time away from work, including vacations, holidays, sick days and certain time away on a paid or unpaid leave of absence. You receive credit for Vesting Service beginning with your first day of employment with the Company and its Affiliates and ending on the date your employment with the Company and its Affiliates ends. (See the Retirement Plan SPD booklet for more details.) The Prudential Wellness Plan Page 49

55 2013 The Prudential Insurance Company of America 751 Broad Street, Newark, NJ ALL RIGHTS RESERVED. ORD Ed. 04/2013