Amazon And Subsidiaries

Amazon And Subsidiaries

Standard Plan

4000083

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INTRODUCTION TO YOUR STANDARD PLAN

This plan is self-funded by Amazon and Subsidiaries ("the Group"), which means that the Group is financially responsible for the payment of plan benefits. The Group has the final discretionary authority to determine eligibility for benefits and claims and to construe the terms of the plan. The Group has contracted with Premera Blue Cross, an Independent Licensee of the Blue Cross Blue Shield Association, to process claims and for other administrative duties. The Group has delegated to us the discretionary authority to determine claims for benefits and to construe the terms used in this plan to the extent necessary to perform our services. Premera Blue Cross doesn't insure this plan. In this booklet Premera Blue Cross is called the "Claims Administrator." This booklet replaces any other health plan benefit booklet you may have. This plan will comply with the 2010 federal health care reform law, called the Affordable Care Act (see "Definitions"). If Congress, federal or state regulators, or the courts make further changes or clarifications regarding the Affordable Care Act and its implementing regulations, including changes which become effective on the beginning of the plan year, this plan will comply with them even if they are not stated in this booklet or if they conflict with statements made in this booklet.

Group Name: Amazon and Subsidiaries Effective Date: April 1, 2016 Group Number: 4000083

Plan: Standard Plan Certificate Form Number: AMZN16S

LEGAL124117900.2

HOW TO USE THIS BOOKLET This booklet will help you get the most out of your benefits. Every section contains important information, but the ones below may be particularly useful: Medical Care Summary of Costs ? Table of cost-shares How Does Selecting A Provider Affect My Benefits? -- How using in-network providers will cut your costs. What Types Of Expenses Am I Responsible For Paying? ? Your copays, deductible and coinsurance. What Are My Benefits? -- What's covered and what you need to pay for covered services. Prior Authorization ? Describes services that are recommended for prior authorization and emergency

admission notification. What's Not Covered? -- Services that are either limited or not covered under this plan. Who Is Eligible For Coverage?-- Eligibility requirements for this plan. How Do I File A Claim? -- Step-by-step instructions for claims submission. Complaints And Appeals -- Processes to follow if you want to file a complaint or an appeal. Definitions -- Terms that have specific meanings under this plan. Example: "You" and "your" refer to

members under this plan. "We," "us," "our" or "Claims Administrator" refer to Premera Blue Cross. FOR MORE INFORMATION Our contact information is on the last page of this booklet. Please visit our Web site or call Customer Service for help with: Questions about benefits or claims Questions or complaints about care you receive You can also get benefit and claim information through our self-service automated system when you call Customer Service. Online information about your plan is at your fingertips whenever you need it You can use our Web site to: Locate a health care provider near you Get details about the types of expenses you're responsible for and this plan's benefit maximums Check the status of your claims Visit our health information resource to learn about diseases, medications, and more

LEGAL124117900.2

TABLE OF CONTENTS

CONTACT THE CLAIMS ADMINISTRATOR ............... (SEE LAST PAGE OF THIS BOOKLET) MEDICAL CARE SUMMARY OF COSTS ....................................................................................................3 HOW DOES SELECTING A PROVIDER AFFECT MY BENEFITS?...........................................................1 WHAT TYPES OF EXPENSES AM I RESPONSIBLE FOR PAYING? .......................................................2 WHAT ARE MY BENEFITS?........................................................................................................................3

Medical Services .....................................................................................................................................5 Routine Hearing Exams ........................................................................................................................35 Hearing Hardware .................................................................................................................................35 PROVIDERS OUTSIDE OF WASHINGTON AND ALASKA .....................................................................36 Out-Of-Area Care..................................................................................................................................36 CARE MANAGEMENT ...............................................................................................................................38 Prior Authorization.................................................................................................................................38 Clinical Review......................................................................................................................................40 Personal Health Support .......................................................................................................................40 WHAT'S NOT COVERED?.........................................................................................................................40 Limited And Non-Covered Services......................................................................................................40 WHAT IF I HAVE OTHER COVERAGE? ...................................................................................................46 Coordinating Benefits With Other Health Care Plans ...........................................................................46 Subrogation And Reimbursement.........................................................................................................48 WHO IS ELIGIBLE FOR COVERAGE? .....................................................................................................49 Subscriber Eligibility ..............................................................................................................................49 Dependent Eligibility..............................................................................................................................50 WHEN DOES COVERAGE BEGIN? ..........................................................................................................51 Enrollment .............................................................................................................................................51 Special Enrollment ................................................................................................................................51 Other Special Enrollment ......................................................................................................................52 Open Enrollment ...................................................................................................................................53 Changes In Coverage ...........................................................................................................................53 Plan Transfers.......................................................................................................................................53 WHEN WILL MY COVERAGE END? .........................................................................................................54 Events That End Coverage ...................................................................................................................54 Plan Termination ...................................................................................................................................54 HOW DO I CONTINUE COVERAGE?........................................................................................................54 Continued Eligibility For A Disabled Child.............................................................................................54 Continued Eligibility While On Short Term Disability For Medical Leave .............................................54

Standard Deductible Plan (Non-Grandfathered)

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January 1, 2016

Leave Of Absence.................................................................................................................................54 COBRA..................................................................................................................................................54 Extended Benefits .................................................................................................................................57 Continuation Under USERRA ...............................................................................................................57 Medicare Supplement Coverage ..........................................................................................................57 HOW DO I FILE A CLAIM? ........................................................................................................................58 COMPLAINTS AND APPEALS ..................................................................................................................59 OTHER INFORMATION ABOUT THIS PLAN............................................................................................63 ERISA PLAN IDENTIFYING INFORMATION ............................................................................................64 WHAT ARE MY RIGHTS UNDER ERISA? ................................................................................................65 DEFINITIONS ..............................................................................................................................................66

Standard Deductible Plan (Non-Grandfathered)

2

4000083

January 1, 2016

MEDICAL CARE SUMMARY OF COSTS

This is a summary of your costs for covered services. Your costs are subject to the all of the following:

The allowable charge. This is the most this plan allows for a covered service. See "Definitions" for details.

The conditions, time limits and maximum limits described in this contract. Some services have special rules. See What Are My Benefits? for these details.

The plan year deductible is the amount of expense you must incur in each plan year (April 1 through March 31) for most covered services and supplies before this plan provides benefits. The plan year deductible amount required when services are furnished by in-network providers and the plan year deductible amount required when services are furnished by out-of-network providers are cross-applied. This means that any plan year deductible amount you pay for any covered service or supply helps satisfy the plan year deductible requirement of the other benefit level.

Individual deductible Family deductible

In-Network Providers $300 $900

Out-of-Network Providers $600 $1,800

The out-of-pocket maximum is the most you pay each year for services from all providers. The out-of-pocket maximum required when services are furnished by in-network providers and the out-of-pocket maximum required when services are furnished by out-of-network providers are cross-applied. This means that any coinsurance amount you pay for any covered service or supply helps satisfy the coinsurance requirement of the other benefit level.

Individual out-of-pocket maximum Family out-of-pocket maximum

In-Network Providers $2,300 $4,900

Out-of-Network Providers $4,600 $9,800

Please note: The cost-shares shown in the table below apply after the deductible has been met. Sometimes the deductible is waived and this is also shown below. Additionally, if the provider you see is an out-of-network provider, you'll also be responsible for amounts above the allowable charge, in addition to any applicable deductible, coinsurance, amounts in excess of stated benefit maximums, and charges for non-covered services and supplies. Amounts in excess of the allowable charge do not count toward the plan year deductible or out-ofpocket maximum.

COMMON MEDICAL SERVICES

Professional Visits And Services (You may have additional costs for things such as x-rays. See those covered services for details.)

Urgent Care Virtual Care (electronic visits and telehealth

services) Therapeutic injections

IN-NETWORK PROVIDERS

10%

$75 copay, deductible & 10% 10% 10%

OUT-OF-NETWORK PROVIDERS

30%

$75 copay, deductible & 30% 30% 30%

Standard Deductible Plan (Non-Grandfathered)

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January 1, 2016

COMMON MEDICAL SERVICES

Preventive Care Exams, screenings and immunizations Seasonal and travel immunizations Preventive colon health screenings including

colonoscopies, sigmoidoscopies and double contract barium enemas (facility, anesthesia and professional charges) Please see the surgical services benefit for coverage of non-preventive diagnostic surgeries.

Health Management Health education, diabetes health education, community wellness and nicotine dependency treatment

Chemical Dependency Treatment Office visits Outpatient facility care Inpatient facility care

Contraception Management and Sterilization Female Contraceptive Management and

Sterilization Male Contraceptive Management and Sterilization

Diagnostic Services Preventive & screening diagnostic services Non-preventive diagnostic services

Diagnostic and Screening Mammography Preventive & screening mammography Non-preventive diagnostic mammography

Surgical Services Inpatient hospital Outpatient hospital, ambulatory surgical center Professional services

Emergency Room

Facility fees Emergency room physician services Diagnostic services Other services and supplies

Standard Deductible Plan (Non-Grandfathered) 4000083

IN-NETWORK PROVIDERS

$0, deductible waived $0, deductible waived

$0, deductible waived

$0, deductible waived

10% 10% 10%

$0, deductible waived $0, deductible waived

$0, deductible waived 10%

$0, deductible waived 10%

10% 10% 10%

$150 copay, deductible & 10% 10% 10% 10%

4

OUT-OF-NETWORK PROVIDERS

$0, deductible waived $0, deductible waived

$0, deductible waived

$0, deductible waived

30% 30% 30%

$0, deductible waived $0, deductible waived

$0, deductible waived 30%

$0, deductible waived 30%

30% 30% 30%

$150 copay, deductible & 10% 10% 10% 10%

January 1, 2016

COMMON MEDICAL SERVICES

Ambulance Services

Hospital Services (Inpatient & Outpatient)

Mental Health Care Office visits Outpatient facility care Inpatient facility care

Maternity and Newborn Care Prenatal, postnatal, delivery and inpatient care Hospital Birthing center or short-stay facility Diagnostic tests during pregnancy Professional care

Home Health Care Limited to 130 visits per plan year (shared limit with acute nursing.)

Hospice Care Home visits and respite care (unlimited) Inpatient hospice care (unlimited)

Rehabilitation Therapy and Chronic Pain Care Inpatient (unlimited) Outpatient (physical, occupational and speech

therapy are limited to 60 visits per plan year) Chronic pain care (unlimited)

Skilled Nursing Facility

Medical Equipment and Supplies Breast pumps

Coverage is provided for standard electric breast pumps or the rental of hospital grade pumps Please Note: The purchase of hospital grade pumps is not covered. Medical vision hardware Wigs or Hairpieces (1 every 365 days, up to a $500 benefit maximum) Foot orthotics and orthopedic shoes

IN-NETWORK PROVIDERS

10% 10%

10% 10% 10%

10% 10% 10% 10%

10%

10% 10%

10% 10% 10% 10%

$0, deductible waived

10% 10% 10%

OUT-OF-NETWORK PROVIDERS

10% 30%

30% 30% 30%

30% 30% 30% 30%

30%

30% 30%

30% 30% 30% 30%

$0, deductible waived

30% 10% 30%

Standard Deductible Plan (Non-Grandfathered)

5

4000083

January 1, 2016

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