ADMINISTRATION OF THE PLAN, IT IS UNDERSTOOD AND AGREED THAT THE FOLLOWING MODIFICATIONS SHALL BE MADE EFFECTIVE JANUARY 1, 2019:

In both the SCHEDULE OF MEDICAL BENEFITS – BLACK PLAN and SCHEDULE OF MEDICAL BENEFITS – ORANGE PLAN sections of the Plan document, the following note shall be added to the HEARING CARE benefit:

NOTE: Certain services billed by a Physician or that are performed for the maintenance or reprogramming of a hearing aid (or other eligible device) are not eligible for coverage under this benefit and are instead are eligible for coverage under the Plan’s Outpatient Physician Visits benefit. In such instances, an office visit co-payment may be charged for In-Network services (cost-sharing provisions will depend on whether the provider is a Specialist or Non- Specialist, as well as the type of service rendered). Please see the Hearing Care benefit for more information about services eligible for coverage under this benefit.

IT IS UNDERSTOOD AND AGREED THAT THE FOLLOWING MODIFICATIONS SHALL BE MADE EFFECTIVE JULY 1, 2020:

1. In the COMPREHENSIVE MEDICAL EXPENSE BENEFIT – COVERED CHARGES section of the Plan document, the Ambulances provision will be revised to read as follows:
   
   Ambulances:
   Charges for professional ambulance service (ground or air) to or from a facility where appropriate care or treatment may be rendered or may have been rendered when the Covered Person’s condition mandates such transportation. Benefits are provided for air ambulance transportation when all of the following criteria have been met: (1) the Covered Person is transported to the nearest facility having the capability to treat the condition; (2) no other method of transportation is appropriate (including emergency ground transport); and (3) the Plan Administrator determines that the Covered Person’s condition, the type of service required for the treatment of the Covered Person’s condition, and the type of facility required to treat the Covered Person’s condition justify the use of air ambulance instead of another means of transport.
   
2. In the COMPREHENSIVE MEDICAL EXPENSE BENEFIT – COVERED CHARGES section of the Plan document, the Rehabilitative Therapies provision will be deleted in its entirety and will be replaced with the following provision:
   
   Rehabilitative Services:
   Charges incurred for Physical Therapy, Occupational Therapy, or Speech Therapy treatment or services rendered by a licensed physical therapist, a licensed occupational therapist, or a licensed speech therapist in a home setting or at a facility or institution whose primary purpose is to provide medical care for an Illness or Injury. Covered charges include health care services that assist a Covered Person in restoring or improving skills and functions that have been lost or impaired because of Illness, Injury, or congenital anomaly. However, services for psychosocial dysfunction, idiopathic developmental delays unrelated to an Illness, learning disabilities, Functional Nervous Disorders, socioeconomic differences, and the aging process are not covered.
   
   Outpatient visits are limited to the benefit maximum stated in the Schedule of Benefits.
   
3. In the GENERAL PLAN EXCLUSIONS AND LIMITATIONS section of the Plan document, the Free School-Provided Special Education Services provision will be revised to read as follows:
   
   Free School-Provided Special Education Services:
   Charges for services available to physically or mentally impaired individuals where a school is required to provide those services free of charge (e.g., rehabilitative services or special education).
   
4. In the DEFINITIONS section of the Plan document, the OCCUPATIONAL THERAPY, PHYSICAL THERAPY, and SPEECH THERAPY definitions will be deleted in their entirety and replaced with the following:
   
   OCCUPATIONAL THERAPY:
   The term “Occupational Therapy” means the specialized group of therapy services provided by or under the direction of a licensed occupational therapist that assist a Covered Person in restoring or improving skill and functions that have been lost or impaired because of
   Illness, Injury, or congenital anomaly. Services may include, but are not limited to, evaluation, treatment, and consultation.
   
   PHYSICAL THERAPY
   The term “Physical Therapy” means the specialized group of therapy services provided by or under the direction of a licensed physical therapist that assist a Covered Person in restoring or improving skills and functions that have been lost or impaired because of Illness, Injury, or congenital anomaly. Services may include, but are not limited to, massage, manipulation, therapeutic exercises, cold, heat (including shortwave, microwave, and ultrasonic diathermy), hydrotherapy, electric stimulation, and light.
   
   SPEECH THERAPY
   The term “Speech Therapy” means the specialized group of therapy services provided by or under the direction of a licensed speech therapist that assist a Covered Person in restoring or improving skills and functions that have been lost or impaired because of Illness, Injury, or congenital anomaly. Services may include, but are not limited to, evaluation of motor speech skills, expressive and receptive language skills, writing and reading skills, social interaction skills, and cognitive functioning; and the development of speech, listening, and conversation skills.

All other provisions of the Plan shall remain in effect and unchanged.

IN WITNESS WHEREOF, the undersigned has caused this amendment to be duly adopted and effective as of the July 9, 2020

Signatures on file in Human Resources.