Effective January 1, 2024

Universal Health Services, Inc.

Summary Plan Description
Universal Health Services, Inc. (UHS) is pleased to provide you with an employee
benefits program designed for our diverse workforce. This Summary Plan
Description (SPD) describes the UHS benefit plans available to you. It is intended to
provide both high level summaries and detailed provisions, such as eligibility
requirements and coverage levels.
The SPD includes information about all healthcare, flexible spending accounts,
disability, life and accidental death and dismemberment insurance, supplemental
AD&D insurance, business travel accident, and 401(k) retirement savings plan
benefits available to you. You should use this as your primary reference source
when you have a question about your benefits or your rights as a plan participant.

Contents
Universal Health Services, Inc. Summary Plan Description .................................................................................................................i
About This Summary Plan Description............................................................................................................................................... 1
For More Information ......................................................................................................................................................................... 1
Eligibility and Enrollment .................................................................................................................................................................. 2
Eligibility.............................................................................................................................................................................................. 3
Eligible Dependents ............................................................................................................................................................................ 3
Enrollment .......................................................................................................................................................................................... 5
Other Events That Allow You to Change Elections ............................................................................................................................. 7
Cost of Coverage ................................................................................................................................................................................. 7
When Coverage Begins ....................................................................................................................................................................... 8
When Coverage Ends .......................................................................................................................................................................... 8
When Coverage May Continue ......................................................................................................................................................... 10
Medical ........................................................................................................................................................................................... 14
Your UHS Medical Options................................................................................................................................................................ 16
Medical at a Glance .......................................................................................................................................................................... 17
Coverage Levels ................................................................................................................................................................................ 22
About the Plan Design Options ......................................................................................................................................................... 23
How the Plan Pays Benefits .............................................................................................................................................................. 24
What’s Covered ................................................................................................................................................................................ 27
What’s Not Covered.......................................................................................................................................................................... 32
Prescription Drug Coverage .............................................................................................................................................................. 34
General Plan Provisions .................................................................................................................................................................... 36

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 Universal Health Services, Inc. Summary Plan Description

Terms ................................................................................................................................................................................................ 40
Claims................................................................................................................................................................................................ 42
The Health Savings Account.............................................................................................................................................................. 43
Alternative Health Plans .................................................................................................................................................................. 47
Your ID Card ...................................................................................................................................................................................... 48
Your Options ..................................................................................................................................................................................... 49
About Your Primary Care Physician .................................................................................................................................................. 49
What’s Covered ................................................................................................................................................................................ 50
What’s Not Covered.......................................................................................................................................................................... 51
General Plan Provisions .................................................................................................................................................................... 52
Claims................................................................................................................................................................................................ 52
Member Services .............................................................................................................................................................................. 53
Supplemental Insurance Benefits .................................................................................................................................................... 54
Eligibility............................................................................................................................................................................................ 55
Enrollment ........................................................................................................................................................................................ 55
Plan Features .................................................................................................................................................................................... 56
Cost of Coverage ............................................................................................................................................................................... 56
Accident Insurance ........................................................................................................................................................................... 56
Critical Illness Insurance ................................................................................................................................................................... 61
Wellness Benefit ............................................................................................................................................................................... 63
Claims................................................................................................................................................................................................ 64
Health Care Flexible Spending Accounts .......................................................................................................................................... 65
Health Care FSA at a Glance ............................................................................................................................................................. 66
How You Save ................................................................................................................................................................................... 66
Enrollment ........................................................................................................................................................................................ 66
Funding Your Account....................................................................................................................................................................... 67
Whose Expenses Are Eligible? .......................................................................................................................................................... 68
Eligible Healthcare Expenses ............................................................................................................................................................ 68
Ineligible Expenses ............................................................................................................................................................................ 70
Accessing Your Account .................................................................................................................................................................... 70
If You Take a Leave of Absence......................................................................................................................................................... 71
When Your Employment Ends .......................................................................................................................................................... 72
Dependent Care Flexible Spending Account .................................................................................................................................... 73
How You Save ................................................................................................................................................................................... 74
Enrollment ........................................................................................................................................................................................ 74
Funding Your Account....................................................................................................................................................................... 75
Whose Expenses Are Eligible? .......................................................................................................................................................... 75
Eligible Expenses ............................................................................................................................................................................... 76
Ineligible Expenses ............................................................................................................................................................................ 77
Accessing Your Account .................................................................................................................................................................... 77
Claiming Reimbursement ................................................................................................................................................................. 77
If You Take a Leave of Absence......................................................................................................................................................... 78

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 Universal Health Services, Inc. Summary Plan Description

When Your Employment Ends .......................................................................................................................................................... 79

Dental Plan ...................................................................................................................................................................................... 80
Dental at a Glance............................................................................................................................................................................. 81
How the Plan Pays Benefits .............................................................................................................................................................. 81
What’s Covered ................................................................................................................................................................................ 82
What’s Not Covered.......................................................................................................................................................................... 84
Coordination of Benefits ................................................................................................................................................................... 85
Claims................................................................................................................................................................................................ 85
Vision Plan ...................................................................................................................................................................................... 86
Vision at a Glance ............................................................................................................................................................................. 87
What’s Covered ................................................................................................................................................................................ 87
What’s Not Covered.......................................................................................................................................................................... 89
Claims................................................................................................................................................................................................ 89
Life and Accidental Death & Dismemberment Plan ......................................................................................................................... 91
Life and AD&D Insurance at a Glance ............................................................................................................................................... 92
Eligibility............................................................................................................................................................................................ 92
Cost of Coverage ............................................................................................................................................................................... 93
How Life Insurance Works ................................................................................................................................................................ 93
How AD&D Insurance Works ............................................................................................................................................................ 95
Additional Benefits ........................................................................................................................................................................... 97
General Life and AD&D Information ................................................................................................................................................. 99
Designating Beneficiaries ................................................................................................................................................................ 100
Claims.............................................................................................................................................................................................. 100
When Coverage Ends ...................................................................................................................................................................... 101
Dependent Life Insurance.............................................................................................................................................................. 102
Dependent Life Insurance at a Glance ............................................................................................................................................ 103
Eligible Dependents ........................................................................................................................................................................ 103
How to Apply .................................................................................................................................................................................. 103
Cost of Coverage ............................................................................................................................................................................. 104
General Plan Provisions .................................................................................................................................................................. 104
Claims.............................................................................................................................................................................................. 106
When Coverage Ends ...................................................................................................................................................................... 106
Supplemental AD&D ..................................................................................................................................................................... 107
Supplemental AD&D insurance at a Glance.................................................................................................................................... 108
Enrollment ...................................................................................................................................................................................... 109
General Information ....................................................................................................................................................................... 110
How Benefits Are Paid .................................................................................................................................................................... 110
Additional Benefits ......................................................................................................................................................................... 111
What's Not Covered........................................................................................................................................................................ 114
Claims.............................................................................................................................................................................................. 115
When Coverage Ends ...................................................................................................................................................................... 115
Business Travel Accident Insurance ............................................................................................................................................... 117

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 Universal Health Services, Inc. Summary Plan Description

Eligibility.......................................................................................................................................................................................... 117
Enrollment ...................................................................................................................................................................................... 117
How Benefits Are Paid .................................................................................................................................................................... 118
What's Not Covered........................................................................................................................................................................ 119
Designating Beneficiaries ................................................................................................................................................................ 119
Claims.............................................................................................................................................................................................. 119
When Coverage Ends ...................................................................................................................................................................... 120
Short-Term Disability..................................................................................................................................................................... 121
Short-Term Disability at a Glance ................................................................................................................................................... 122
Eligibility.......................................................................................................................................................................................... 122
Enrollment ...................................................................................................................................................................................... 122
Cost of Coverage ............................................................................................................................................................................. 123
How STD Works .............................................................................................................................................................................. 123
General Plan Provisions .................................................................................................................................................................. 124
What’s Not Covered........................................................................................................................................................................ 125
Claims.............................................................................................................................................................................................. 125
When Coverage Ends ...................................................................................................................................................................... 126
Long-Term Disability...................................................................................................................................................................... 127
Long-Term Disability at a Glance .................................................................................................................................................... 128
Eligibility.......................................................................................................................................................................................... 128
Enrollment ...................................................................................................................................................................................... 128
Cost of Coverage ............................................................................................................................................................................. 129
How LTD Works .............................................................................................................................................................................. 129
Definition of Disability .................................................................................................................................................................... 131
How Benefits Are Paid .................................................................................................................................................................... 131
General Plan Provisions .................................................................................................................................................................. 132
What's Not Included ....................................................................................................................................................................... 135
Claims.............................................................................................................................................................................................. 135
When Coverage Ends ...................................................................................................................................................................... 136
Retirement Savings Plan ................................................................................................................................................................ 137
How the Plan Works ....................................................................................................................................................................... 139
Eligibility.......................................................................................................................................................................................... 139
About Your Contributions ............................................................................................................................................................... 141
Your Plan Contributions .................................................................................................................................................................. 142
Qualified Non-Elective Contributions ............................................................................................................................................. 144
Company Matching Contributions .................................................................................................................................................. 144
Your Investment Choices ................................................................................................................................................................ 146
Accessing Your Assets While Employed .......................................................................................................................................... 148
Distributions When You Leave the Company ................................................................................................................................. 151
Understanding Your 401(k) Plan Participation ............................................................................................................................... 154
Plan Administration Information .................................................................................................................................................... 156
Non-Assignment of Benefits ........................................................................................................................................................... 159

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 Universal Health Services, Inc. Summary Plan Description

Future of the Plan ........................................................................................................................................................................... 159

Top Heavy Provisions ...................................................................................................................................................................... 159
Qualified Domestic Relations Order ............................................................................................................................................... 159
Claims.............................................................................................................................................................................................. 160
Appendix A – Participation from a Prior Plan ................................................................................................................................. 161
Plan Administration Information ................................................................................................................................................... 162
Plan Sponsor and Administrator ..................................................................................................................................................... 163
The Employer Identification Numbers (EIN) ................................................................................................................................... 163
The Plan Numbers........................................................................................................................................................................... 164
The Plan Year End ........................................................................................................................................................................... 164
Plan Administrator and Plan Sponsor ............................................................................................................................................. 164
General Counsel .............................................................................................................................................................................. 164
Plan Funding ................................................................................................................................................................................... 164
Claims Administrators ..................................................................................................................................................................... 165
Plan Amendment and Termination ................................................................................................................................................ 165
Plan Interpretation ......................................................................................................................................................................... 166
Plan Document ............................................................................................................................................................................... 166
Federal Notices ............................................................................................................................................................................... 166
Claims Appeals ................................................................................................................................................................................ 168
Health Claim Filing and Appeal Procedures .................................................................................................................................... 169
Non-Health Claim Filing and Appeal Procedures ............................................................................................................................ 176
Statement of ERISA Rights .............................................................................................................................................................. 178
Schedule of Insurance Carriers or Claims Administrators .............................................................................................................. 180
Employee Privacy Notice ................................................................................................................................................................ 182

Effective January 1, 2024 v

About This Summary Plan
Description
UHS provides this SPD for your use as a reference and summary of your benefit plans. It is intended to help
you use each plan’s benefits more effectively and highlights actions or situations that could limit the benefits
you and your enrolled dependents may receive.
The descriptions in this SPD provide you with most of the information you will need to know about your UHS
employee benefits plan. However, these descriptions provide only a summary of these benefits and are not
intended to cover all the details. Additional details are provided in the plan documents, including:
 plan documents for the individual plans
 insurance contracts, policies or certificates of coverage for certain plans
 the trust agreement pursuant to which the assets of the retirement plan are held.
Every effort has been made to ensure that the information in this SPD is complete and accurate. However, if
there is an inconsistency between any of the terms of the applicable plan documents or this SPD with regard
to plan benefits, the plan document(s) will govern and be enforced consistent with their terms.
This SPD also describes your rights under the Employee Retirement Income Security Act (ERISA), the
Consolidated Omnibus Budget Reconciliation Act (COBRA) for you and your covered dependents, and the
Health Insurance Portability and Accountability Act (HIPAA). See the “Plan Administration Information”
section” section of this SPD on page 162 for a description of these rights. The Plan will provide benefits in
accordance with applicable federal laws including COBRA, HIPAA, the Newborns’ and Mothers’ Health
Protection Act (NMHPA), the Women’s Health and Cancer Rights Act (WHCRA), the Mental Health Parity and
Addiction Equity Act of 2008 (MHPAEA), the Genetic Information Nondiscrimination Act (GINA), and the
applicable provisions of the Patient Protection and Affordable Care Act as amended by the Health Care and
Education Reconciliation Act (the Affordable Care Act).
The Plan also will be enforced consistent with the plan documents in the event of a conflict between the plan
documents and any oral representation concerning plan benefits. Additionally, all benefits will be managed
and governed by all applicable laws and regulations.

FOR MORE INFORMATION

Visit the UHS Benefits Portal and Self-Service Center at https://uhsbenefits.ehr.com for a complete list of
benefit options and plan costs.
If you need assistance in determining your benefits, you may contact your local Human Resources Department
or the UHS Benefits Service Center at (855) 847-4002.

Effective January 1, 2024 1

 Eligibility and Enrollment
The eligibility and enrollment requirements described in this section apply to all
plans in this Summary Plan Description (SPD), unless otherwise stated.

In this Section
Eligibility............................................................................................................................................................................................ 3
Eligible Dependents ........................................................................................................................................................................... 3
Disabled Dependent Children ............................................................................................................................................................. 4
Enrollment ........................................................................................................................................................................................ 5
Qualified Life Events ........................................................................................................................................................................... 5
Consistency Requirements for Qualified Life Events .......................................................................................................................... 6
Other Events That Allow You to Change Elections .............................................................................................................................7
Entitlement to Government Benefits ................................................................................................................................................. 7
Qualified Medical Child Support Order............................................................................................................................................... 7
Loss of Other Group Health Plan Coverage ........................................................................................................................................ 7
Cost of Coverage ............................................................................................................................................................................... 7
When Coverage Begins ...................................................................................................................................................................... 8
Special Enrollment Rights ................................................................................................................................................................... 8
Medicaid and CHIP Special Enrollment Rights .................................................................................................................................... 8
When Coverage Ends ......................................................................................................................................................................... 8
Medicaid and CHIP Special Enrollment Rights .................................................................................................................................... 9
Coordination with Medicare ............................................................................................................................................................... 9
Coordination with Medicaid ............................................................................................................................................................. 10
COBRA — Your Right to Elect Continuation Benefits........................................................................................................................ 10
When Coverage May Continue ........................................................................................................................................................ 10
Leave of Absence .............................................................................................................................................................................. 10
Military Leave ................................................................................................................................................................................... 11
USERRA and COBRA Continuation Coverage .................................................................................................................................... 12
Leave for Qualifying Exigency ........................................................................................................................................................... 13
Military Caregiver Leave ................................................................................................................................................................... 13

Effective January 1, 2024 2

 Eligibility and Enrollment

ELIGIBILITY
You are eligible to enroll in these plans 30 days following the date you begin employment or change to a
benefit-eligible status with a Universal Health Services, Inc. (UHS) subsidiary that has adopted to participate in
this Plan, provided you are regularly scheduled to work a minimum of 30 hours per week and you are not
covered by a collective bargaining agreement, unless the agreement provides for such coverage. Eligibility for
employees scheduled to work less than 30 hours per week may vary by UHS location.
Employees with variable work schedules may be eligible for medical benefits only if they average at least 30
hours per week over the course of a measurement period determined in accordance with rules set forth under
the Affordable Care Act. If you become eligible due to a change in your work schedule or due to your actual
hours credited over the course of a set measurement period, you will receive notification with plan, payment
and enrollment information.
Some medical options may not be available at all UHS locations. Check with your Human Resources
Department to confirm your eligibility. You must enroll to be covered by any benefit plan except Basic Life and
Accidental Death and Dismemberment coverage; you will be automatically enrolled.

ELIGIBLE DEPENDENTS
For plans that provide dependent coverage, your dependents become eligible when you do. You are required
to provide proof of eligibility when you enroll your dependents for coverage.
If you and any of your eligible family members work for UHS, you each must enroll separately. Your spouse
and eligible children may not be covered twice by the same benefit. Either you or your spouse may cover your
eligible children; there is no double coverage. If you have eligible children who also work for UHS, they must
enroll for coverage on their own.

For medical coverage only, eligible dependents are:

 your lawful spouse in accordance with federal law and regulations
 your children, through the end of the month in which the child turns 26, regardless of their student status,
marital status, whether or not they live with you or receive financial support from you. Your eligible
children are:
 your biological children
 your stepchildren
 your legally adopted children, after they have been placed with you and you have assumed legal
obligation for support in anticipation of legal adoption
 children for whom a court order has appointed you or your legal spouse as legal guardian
 your foster children for whom you have been receiving foster care payments

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 Eligibility and Enrollment

For coverage other than medical (i.e., dental, vision, dependent life insurance and
supplemental AD&D insurance), eligible dependents are:
 Your lawful spouse in accordance with federal law and regulations.
 Your unmarried children:
 Your biological children through age 18.
 Your stepchildren through age 18 who (a) reside in your home or (b) qualify as dependents for federal
income tax purposes.
 Your legally adopted children through age 18, after they have been placed with you and you have
assumed legal obligation for support in anticipation of legal adoption.
 Children for whom a court order has appointed you or your legal spouse as legal guardian.
 Your foster children through age 18 for whom you have been receiving foster care payments.
 Your unmarried dependent children, ages 19 through 22, who are full-time students and who are
principally supported by you. A full-time student is defined as earning at least 12 credits per semester
at an accredited college, university, or school of nursing.
Please note: For information about eligible dependents under Supplemental Insurance Benefits, see
“Supplemental Insurance Benefits” on page 54 for more information.
You are required to provide proof of your dependents’ eligibility at time of enrollment or at any other time
upon request. False or misrepresented eligibility information will cause both your coverage and your
dependents’ coverage to terminate irrevocably (retroactive to the extent permitted by law), which may cause
claims reversals for which you are responsible. It may also be grounds for employee discipline, up to and
including termination. Failure to provide timely notice of loss of eligibility may be considered intentional
misrepresentation.

DISABLED DEPENDENT CHILDREN

An unmarried child who is incapable of self-sustaining employment by reason of mental or physical disability
and is primarily dependent on you for maintenance and support may be covered under this Plan regardless of
age, as long as the disability persists and the disability began before the child reached the maximum age for
dependent coverage under the Plan.
In order to obtain coverage, you must furnish written proof of the disability within 31 days following the
child’s loss of eligibility or within 31 days of the dependent’s effective date of coverage, if later. The Plan
Administrator may require you to furnish annual proof of the child’s continued disability. If such proof is not
satisfactory to the Plan Administrator, coverage for the child will end immediately.

Effective January 1, 2024 4

 Eligibility and Enrollment

ENROLLMENT
You must enroll within 31 days of your first date of eligibility to be covered; your coverage effective date is the
31st day of your continuous employment, unless otherwise noted. You may enroll your eligible dependents at
the same time you enroll yourself. If you do not make active elections when eligible to do so, you will not be
covered by any benefits, except basic life and accidental death and dismemberment insurance. You will
receive an enrollment notice when you are eligible to enroll. Your enrollment authorizes UHS to deduct the
necessary employee contributions from your paycheck for you and your dependents' coverage.
Any additional dependents that you acquire after coverage begins must be enrolled within 30 days of the date
you acquire them in order to be covered. Coverage will be effective on the date that you acquire any
additional dependents.

QUALIFIED LIFE EVENTS

You may not change your benefit elections once you have enrolled for the Plan Year, except if you experience
one of the following qualified life events or status changes:
 Marriage, divorce, or legal separation.
 Death of a spouse or child.
 Birth, adoption, or placement for adoption of a child (including placement for legal guardianship).
 You or your spouse has a change of work hours or employment status that affects benefits eligibility.
 You or your spouse start or return from an unpaid leave of absence.
 You are relocated and gain or lose eligibility for one or more benefits.
 Events that are special enrollment events under the Health Insurance Portability and Accountability Act
(HIPAA).
 Your dependent loses eligibility for a particular benefit, such as upon reaching a specific age.
 Any event that causes your dependents to become eligible or ineligible for coverage because of age,
student status, or similar circumstances.
 A change in the place of residence for you or your eligible dependents if the change results in your or your
eligible dependents living outside your medical or dental plan’s network service area.
 Beginning or returning from an unpaid FMLA leave.
 Reduction in hours of service: You may make an election to drop yourself and your dependents from
medical coverage under the plan, even if you remain eligible for such coverage, if:
 You were reasonably expected to work 30 hours per week and you experience a change in
employment, after which you are reasonably expected to work less than 30 hours per week

Effective January 1, 2024 5

 Eligibility and Enrollment

 You intend to enroll yourself and any dependents dropping coverage in another health plan (satisfying
the Affordable Care Act’s definition of minimum essential coverage) effective no later than the first day
of the second month after you drop medical coverage under this plan; however,
 You are not permitted to change your Health Care FSA elections because of a reduction in hours of
service.
 Enrollment in a health plan offered through the public Marketplace:
 If you are eligible for a special enrollment period to enroll in public Marketplace coverage, you may
make an election to drop medical coverage under this plan.
 If your enrolled dependent(s) become eligible for a special enrollment period to enroll in public
Marketplace coverage, you may make an election to drop coverage for them under this plan, but
remain enrolled for yourself (and any covered dependents who did not move to the Marketplace).
 Any individual whose coverage is dropped at this time, must intend to enroll in public Marketplace
coverage that is effective no later than the day immediately following the last day of coverage under
this plan is dropped.
 You are not permitted to change your Health Care FSA elections because you or your dependent intend
to enroll in a plan offered through the public Marketplace.
Any changes in your benefit elections must be made within 30 days from the occurrence of one of the events
mentioned above, except that for a change due to a HIPAA special enrollment event that is a Medicaid or CHIP
Special Enrollment event, the election must be made within 60 days of such event, and the coverage change
will be effective the day the status change occurs. You may make changes only for the benefits affected by the
life event, and proof of the event or status change may be requested. See “Medicaid and CHIP Special
Enrollment Rights” on page 8 for more information.

CONSISTENCY REQUIREMENTS FOR QUALIFIED LIFE EVENTS

Except for election changes due to a HIPAA special enrollment event, the changes you make to your coverage
must be “on account of and correspond with” the qualified life event. To satisfy this “consistency rule,” both
the event and the corresponding change in coverage must meet all the following requirements:
 Effect on eligibility: The event must affect eligibility for coverage under the Plan or under a plan sponsored
by your dependent’s employer. This includes any time you become eligible (or ineligible) for coverage or if
the event results in an increase or decrease in the number of your dependent children who may benefit
from coverage under the Plan.
 Corresponding election change: The election change must correspond with the event. For example, if your
dependent child loses eligibility for coverage under the terms of the health plan, you may cancel health
coverage only for that dependent child. You may not cancel coverage for yourself or other covered
dependents.

Effective January 1, 2024 6

 Eligibility and Enrollment

For Life; Accidental Death and Dismemberment; Supplemental AD&D; Short-Term Disability and/or Long-Term
Disability elections, an increase or decrease in coverage election for any qualifying life event is considered
consistent, even if you do not lose or gain eligibility under the Plan.

OTHER EVENTS THAT ALLOW YOU TO CHANGE ELECTIONS

ENTITLEMENT TO GOVERNMENT BENEFITS

If you or your eligible dependents become entitled to or lose entitlement to Medicare or Medicaid, or lose
entitlement to certain other governmental group medical programs, you may make a corresponding change to
your Medical, Dental, Vision and Health Care FSA elections.

QUALIFIED MEDICAL CHILD SUPPORT ORDER

If a Qualified Medical Child Support Order (QMCSO) requires the Plan to provide coverage to your child, then
the Plan Administrator may automatically change your election under the Plan to provide coverage for that
child. In addition, you may make corresponding election changes as a result of the QMCSO, if you desire. If the
QMCSO requires another person (such as your spouse or former spouse) to provide coverage for the child,
then you may cancel coverage for that child under the Plan if you provide proof to the Plan Administrator that
such other person actually provides the coverage for the child.

LOSS OF OTHER GROUP HEALTH PLAN COVERAGE

If you or your spouse or dependent child lose coverage under another group health plan sponsored by a
governmental or educational institution, including a state children's health insurance program (CHIP), medical
care program of an Indian Tribal government, state health benefits risk pool, or a foreign government group
health plan, you may enroll in coverage under this Plan.

COST OF COVERAGE
Both you and UHS share the cost of providing benefits for you and your dependents. Most administrative
expenses are paid for by UHS. The cost sharing features of each benefit plan are described in this SPD.
Certain premiums are paid on a pre-tax basis. Paying premiums on a pre-tax basis saves you money. Your
premium amount is the same, but the tax savings reduce your final cost, since it is exempt from federal and
Social Security taxes. Certain state and local taxes may apply. The amount of your future Social Security
benefit may be slightly reduced because both you and UHS will pay Social Security taxes on your pay after
contributions to the pre-tax benefits. Your first payroll deduction will begin with the first pay period that
includes the benefits effective date. Retroactive deductions may be due. Annual enrollment changes are
effective January 1st and payroll deductions begin with the first pay date of each calendar year.

Effective January 1, 2024 7

 Eligibility and Enrollment

WHEN COVERAGE BEGINS

If you enroll on or before your eligibility date, coverage for you and your dependents will begin on your
eligibility date.

SPECIAL ENROLLMENT RIGHTS

If you decline enrollment for yourself or your dependents because of other health insurance coverage or
group health plan coverage, you may be able to enroll yourself or your dependents in a UHS health plan if you
or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your
or your dependents' other coverage). However, you must request enrollment within 31 days after your or your
dependents' other coverage ends (or after the employer stops contributing toward the other coverage).
If you acquire a new dependent due to marriage, birth, adoption, or placement for adoption, you may be able
to enroll yourself and your dependent(s). However, you must request enrollment within 30 days of the date
you acquire the new dependent.

MEDICAID AND CHIP SPECIAL ENROLLMENT RIGHTS

You or your dependents (including your spouse) have special enrollment rights and may enroll in a UHS health
plan under the following additional circumstances:
 you or your dependents lose Medicaid or CHIP coverage because you are no longer eligible.
 you or your dependents become eligible for a premium assistance subsidy under Medicaid or CHIP.
You must request coverage for yourself or your dependents within 60 days from the triggering event (that is,
the date Medicaid and CHIP coverage is lost or the date eligibility for premium assistance is determined).

WHEN COVERAGE ENDS

Coverage for you and your dependents will end:
 on the last day of the pay period following the date you terminate employment, retire, or cease to be a
member of an eligible class
 the date that your coverage is terminated by amendment of the Plan, by whole or partial termination of
the Plan, by termination of any insurance contract or agreement, or by discontinuance of contributions by
UHS
 the end of the period for which you paid your required contribution if the contribution for the next period
is not paid when due.
In addition, coverage for your dependent ends when:
 you cease to pay for their coverage
 your dependent becomes ineligible, or becomes a member of the Plan as an employee

Effective January 1, 2024 8

 Eligibility and Enrollment

 the Plan is amended to terminate dependent coverage or a particular benefit coverage

 your dependent enters active, full-time military service
 the end of the month in which your child reaches age 26 (medical only)
 your dependent child reaches age 19 and is not a full-time student (other than medical)
 your dependent child age 19 to 23 is no longer a full-time student; coverage will cease at the end of the
month in which his or her student status ended (other than medical)
 for children covered pursuant to a QMCSO, coverage will end as of the date that the child is no longer
covered under QMCSO.
For dependents reaching the maximum age for coverage, coverage will end on the last day of the month in
which the maximum age is attained.

MEDICAID AND CHIP SPECIAL ENROLLMENT RIGHTS

You or your dependents (including your spouse) have special enrollment rights and may enroll in a UHS health
plan under the following additional circumstances:
 you or your dependents lose Medicaid or CHIP coverage because you are no longer eligible.
 you or your dependents become eligible for a premium assistance subsidy under Medicaid or CHIP.
You must request coverage for yourself or your dependents within 60 days from the triggering event (that is,
the date Medicaid and CHIP coverage is lost or the date eligibility for premium assistance is determined).

COORDINATION WITH MEDICARE

Medicare is a medical insurance program sponsored by the federal government for eligible persons age 65 and
over. If you are actively working and you and/or your spouse is age 65 or over and eligible for Medicare Part A,
you and/or your spouse is entitled to receive the same medical benefits that are provided to employees and
eligible spouses under age 65.
Generally, if you are age 65 or over and covered by Medicare Parts A and B and still employed by UHS, the
Plan will pay benefits on a primary basis with Medicare paying on a secondary basis. This rule also applies if
you are under age 65 and covered by Medicare due to a disability or covered by Medicare for the first 30
months of your Medicare entitlement due to end stage renal disease. If your spouse is also age 65 or over or
your spouse or dependent child is covered under Medicare due to a disability, the Plan will pay benefits on a
primary basis while you remain actively employed by UHS and are covered due to current employment status.
If you are eligible for Medicare but not covered, and Medicare would be your primary payer, the Plan may still
pay benefits as if you are covered by Medicare and will coordinate with the benefits that Medicare would have
paid. You may elect to waive the Plan and carry Medicare Parts A and B as your primary insurance.
For more information about benefits after age 65, contact your local Human Resources Department. You may
also contact the nearest Social Security Administration Office regarding Medicare benefits.

Effective January 1, 2024 9

 Eligibility and Enrollment

COORDINATION WITH MEDICAID

The Plan will not reduce or deny benefits for any participant to reflect that such individual is eligible to receive
medical assistance under a state Medicaid program. The Plan will reimburse any state Medicaid program for
the cost of any items and services provided under the state program that should have been paid for by the
Plan, and the Plan will honor any subrogation rights that a state has to recoup such mistaken payments.

COBRA — YOUR RIGHT TO ELECT CONTINUATION BENEFITS

Under the federal law, the Consolidated Omnibus Budget Reconciliation Act (COBRA), you, and your covered
dependents may elect a temporary extension of health coverage at group rates in certain instances, where
coverage under this Plan would otherwise end. When you first become eligible for benefits, an Initial Notice of
COBRA Continuation Rights is mailed to your home address. Please refer to this important notice for more
information. Another COBRA rights notice will be mailed to your home address at the time you lose medical,
dental and/or vision coverage.

WHEN COVERAGE MAY CONTINUE

Your coverage may continue in certain situations, as described below.

LEAVE OF ABSENCE
You may continue your benefits for a maximum period of six months in a twelve-month period if you take an
approved leave of absence, including a leave of absence that qualifies as a family or medical leave under the
federal Family and Medical Leave Act (FMLA). Contact your local Human Resources Department for more
information about qualifying for FMLA.
If your request for a leave is approved, coverage for you and your covered dependents continues as long as
you continue to pay the cost for your benefits during the leave, including any premium changes that may
occur while you are on a leave. For your own medical leave (FMLA or non-FMLA), you are responsible for the
same premium amount for which you would be responsible as an active employee. If you are on an approved
parental or family care leave (FMLA), you pay the portion of premium you would pay as an active employee
for medical, dental, and vision coverage. You continue to pay the full premium (no employer subsidy) for your
supplemental AD&D, dependent life, short- and long-term disability coverages, if applicable.
If your leave is a paid leave (paid on UHS payroll), the cost of coverage will continue to be deducted from your
pay on a pre- or post-tax basis, as applicable to each benefit. If your leave is unpaid, or paid by a third-party,
you must pay your employee contributions on a monthly basis, but on a post-tax basis because you will not
have any pay from which contributions can be deducted. Billing notices with instructions will be mailed to your
home address.

Effective January 1, 2024 10

 Eligibility and Enrollment

UHS may terminate coverage if your payment is more than 30 days late. If you return to work during the same
year in which your leave began, you may elect reinstatement in your benefit elections that were in place
before the start of your leave, subject to any changes that are permitted due to a mid-year election change
event or a HIPAA special enrollment event. If you return to work in a new year, you may make all new benefit
elections.
Note: if you do not pay the premiums due during your leave, your coverage will be terminated retroactive
to the last day for which premium was received and COBRA continuation coverage will not be offered. If you
return to work and have not made premium payments, you may re-enroll in benefits effective the first day you
return to work; however, you may have a lapse in coverage. If you decide to re-enroll due to this qualified life
event you must make your benefit elections within 30 days from when you return to work.
Special rules apply to your Health Care Flexible Spending Account (Health Care FSA). When you take an unpaid
leave, the entire amount you elected under your Health Care FSA will be available to you during your leave
period, less any prior reimbursement. While you are on an unpaid leave of absence, you cannot make
payments for your FSA. However, upon your return from an unpaid leave of absence your Health Care FSA will
automatically recalculate the per pay period contribution amount based on the number of remaining pay
periods in the year.
If your benefits, including both FSA plans, terminate during your leave due to non-payment or exceeding the
six-month maximum, you will have the opportunity to re-enroll within 30 days from your return to work date,
however, you may have a lapse in coverage. If you choose to re-enroll in the FSA plans, you may not
retroactively elect coverage for expenses incurred after your coverage terminated.
Any coverages that are terminated during your FMLA leave will be reinstated upon your return without any
evidence of good health or newly imposed waiting period.
If you lose any group health coverage during an FMLA leave because you did not make the required
contributions, you may re-enroll when you return from your leave. Your group health coverage will start again
on the first day after you return to work, provided you enroll and make your required contributions.
If you terminate employment at the end of a leave, you will be eligible for COBRA continuation coverage so
long as you have active coverage. If you were not enrolled for coverage on the date your leave started or if
your coverage was terminated due to non-payment, COBRA continuation coverage for that benefit does not
apply.

MILITARY LEAVE
As required by the Uniformed Services Employment and Reemployment Rights Act (USERRA), if you go on
military leave, either voluntarily or involuntarily, you may elect to continue group health coverage for yourself
and your covered dependents, if any. You must give advance notice (with certain exceptions) of the leave. The
cumulative length of the leave and all previous periods of military leave from UHS may not exceed five years
(unless extended by national emergency or similar circumstances). There are a number of exceptions,
however, such as types of service that are not counted toward the five-year limit — including situations where

Effective January 1, 2024 11

 Eligibility and Enrollment

service members are involuntarily retained beyond their obligated service date; additional required training;
federal service as a member of the National Guard; and service under orders during war or national
emergencies declared by the President or Congress. Additionally, the maximum time period may be extended
due to your hospitalization or convalescence following service-related injuries after your uniformed service
ends.
Your USERRA continuation coverage may be continued for up to 24 months from the date your leave of
absence begins. It will terminate earlier if one of the following events occurs:
 you fail to pay any premium within the required time
 you lose your USERRA rights due to a dishonorable discharge or other conduct specified in USERRA
 you fail to report to work or apply for reemployment following the completion of your service within the
time required by USERRA according to the following chart:
If Your Period of Uniformed Service Is: You Must Report to Work or Submit an Application for
Reemployment No Later Than:

Less Than 31 Days The beginning of the first regularly scheduled work period on the day
(Or if you are absent for purposes of an following the completion of your service after allowing for safe travel home
examination to determine your fitness to perform and an 8-hour rest period, or if that is unreasonable or impossible through
uniformed services) no fault of your own, as soon as possible.1

More Than 30 days But Less Than 181 days 14 days after completion of your military service or if that is unreasonable
or impossible through no fault of your own, as soon as possible.1

More Than 180 days 90 days after completion of your service.1

1 If you are hospitalized for, or are convalescing from, an injury or illness incurred or aggravated as a result of your service, the applicable time
periods begin when you have recovered from your injuries or illness rather than upon completion of your service. The maximum period for
recovery is generally two years from completion of service.

If you do not return to work at the end of your military leave, you may be entitled to COBRA continuation
coverage if you extended benefits for less than 18 months.

USERRA AND COBRA CONTINUATION COVERAGE

USERRA and COBRA continuation coverage run concurrently, which means that they begin at the same time.
However, COBRA continuation coverage can continue for up to 18 months (and for longer periods under
certain circumstances) while, as noted above, USERRA coverage can continue for up to 24 months. In addition,
COBRA continuation coverage is subject to early termination for additional reasons that do not apply to
USERRA coverage. When you first become eligible for benefits, an Initial Notice of COBRA Continuation Rights
is mailed to your home address. Please refer to this important notice for more information.

Payment of Premiums under USERRA

If the entire length of the leave is 30 days or less, you will not be required to pay any more than the
contributions required for active employees. If the entire length of the leave is 31 days or longer, you may be

Effective January 1, 2024 12

 Eligibility and Enrollment

required to pay up to 102% of the full amount necessary to cover an employee (including any amount for
dependent coverage) who is not on military leave. The manner in which your required contribution is made
will be determined by UHS and will be consistent with the payment of the required contribution for an unpaid
leave of absence.

LEAVE FOR QUALIFYING EXIGENCY

An eligible employee may take special circumstances leave for any “qualifying exigency” while the employee’s
spouse, son, daughter, or parent is on active duty in the armed services or is called to active duty in support of
a war or national emergency. These circumstances include:
 short notice of deployment (seven days or less)
 military events and related activities
 child care
 school activities
 financial and legal arrangements
 counseling
 rest and recuperation
 post-deployment activities
 additional activities arising out of the covered military member’s active duty or call to active duty status.
The specific terms of this leave policy will be in compliance with the final regulations under the National
Defense Authorization Act (NDAA).

MILITARY CAREGIVER LEAVE

An eligible employee may take up to 26 weeks of special circumstances leave during a 12-month period to
care for a spouse, son, daughter, parent, or “next of kin” member of the armed services (including the
National Guard or Reserves) who is undergoing medical treatment, recuperation, or therapy for a serious
injury or illness suffered while on active duty. The specific terms of this leave policy will be in compliance with
the final regulations under the NDAA.

Effective January 1, 2024 13

 Medical
The Universal Health Services (UHS) Medical Plan provides comprehensive medical
coverage for a broad range of services and is designed to protect you and your
family against the high cost of medical care. Benefits are payable for hospital stays,
doctor's fees, X-rays, and other necessary medical services and supplies. You are
automatically covered for prescription drug benefits when you enroll in the plan.
UHS encourages you to take full advantage of the medical plan to assure good
health for you and your family. If you have questions about your benefits, please
contact the UHS Benefits Service Center at (855) 847-4002.

In this Section
Your UHS Medical Options .............................................................................................................................................................. 16
Medical at a Glance ......................................................................................................................................................................... 17
2024 Preferred Provider Organizations (PPO) .................................................................................................................................. 17
Schedule of Benefits ......................................................................................................................................................................... 17
2024 Exclusive Provider Organization (EPO)..................................................................................................................................... 19
Schedule of Benefits ......................................................................................................................................................................... 19
2024 Out of Area Plan ....................................................................................................................................................................... 21
Schedule of Benefits ......................................................................................................................................................................... 21
Coverage Levels ............................................................................................................................................................................... 22
About the Plan Design Options ........................................................................................................................................................ 23
Preferred Provider Organization....................................................................................................................................................... 23
Exclusive Provider Organization ....................................................................................................................................................... 23
Out of Area Plan................................................................................................................................................................................ 24
How the Plan Pays Benefits ............................................................................................................................................................. 24
Deductible ......................................................................................................................................................................................... 24
Calendar Year Deductible ................................................................................................................................................................. 24
Coinsurance and Copayments .......................................................................................................................................................... 25
Reasonable and Customary Charge .................................................................................................................................................. 25
No Maximum Lifetime Benefit .......................................................................................................................................................... 25
Annual Out-of-Pocket Maximum ...................................................................................................................................................... 25
Maximum Out-of-Pocket Expense .................................................................................................................................................... 26
Pre-Admission Certification/Concurrent Review .............................................................................................................................. 26
Prior Authorization ........................................................................................................................................................................... 26
Special Rights for Mothers and Newborn Children .......................................................................................................................... 26

Effective January 1, 2024 14

 Medical

What’s Covered ............................................................................................................................................................................... 27

Telehealth ......................................................................................................................................................................................... 27
Hospital Expense Benefits................................................................................................................................................................. 27
Surgical Expense Benefits ................................................................................................................................................................. 28
Preventive Care Benefit .................................................................................................................................................................... 28
Breast Cancer Screening ................................................................................................................................................................... 28
Major Medical Benefits..................................................................................................................................................................... 29
Home Health Care............................................................................................................................................................................. 30
Hospice Care ..................................................................................................................................................................................... 30
Infertility Treatment ......................................................................................................................................................................... 31
Spinal Manipulation .......................................................................................................................................................................... 31
Mental Health/Substance Abuse Benefits ........................................................................................................................................ 31
Women's Health and Cancer Rights Act ........................................................................................................................................... 32
What’s Not Covered ........................................................................................................................................................................ 32
Prescription Drug Coverage ............................................................................................................................................................. 34
PrudentRx Program .......................................................................................................................................................................... 36
Specialty Drug Manufacturer Copay Assistance Programs ............................................................................................................... 36
General Plan Provisions ................................................................................................................................................................... 36
Coordination of Benefits ................................................................................................................................................................... 37
Assignment of Rights (Subrogation) and the Right of Recovery ....................................................................................................... 39
Terms .............................................................................................................................................................................................. 40
Physician/Doctor............................................................................................................................................................................... 40
Hospital ............................................................................................................................................................................................. 41
Home Health Care Agency ................................................................................................................................................................ 41
Hospice Agency ................................................................................................................................................................................. 41
Totally Disabled ................................................................................................................................................................................ 42
Claims.............................................................................................................................................................................................. 42
When to File a Claim ......................................................................................................................................................................... 42
How to File a Claim ........................................................................................................................................................................... 42
Payment of a Claim ........................................................................................................................................................................... 42
If a Claim Is Denied ........................................................................................................................................................................... 43
The Health Savings Account ............................................................................................................................................................ 43
Participating in the HSA .................................................................................................................................................................... 43
How the HSA Works .......................................................................................................................................................................... 44
Contributions .................................................................................................................................................................................... 45
Withdrawals ...................................................................................................................................................................................... 45
Accessing Your Health Savings Account............................................................................................................................................ 46

Effective January 1, 2024 15

 Medical

YOUR UHS MEDICAL OPTIONS

For most eligible employees, there are three plan options:
 $600 Deductible Plan
 $1,500 Deductible Plan
 $3,200 High Deductible Health Plan (HDHP) with Health Savings Account (HSA) option.
Each option is available in most locations across the country, but the plan design for your option — which
determines where you can go to receive care that is covered under the plan — depends on your location.
For employees in some locations, there are additional options, including HMOs (Health Maintenance
Organizations). If you are eligible for one of these options, you will be informed, and details on the option(s)
will be provided.
There are three plan designs:
 a Preferred Provider Organization (PPO),
 an Exclusive Provider Organization (EPO), or
 an Out of Area Plan.
The state in which the UHS facility that you work determines the plan design(s) available to you. When you
enroll for coverage, you choose your plan option and the network, based on the network availability for your
state.
The plans are administered by the following carriers through the listed networks:
 Aetna PPO/HDHP: Aetna Choice POS II
 BlueCross BlueShield of TN PPO: BlueCard PPO
 Blue Cross BlueShield of TN EPO: BlueCard PPO
 UnitedHealthcare PPO/HDHP: Choice Plus POS
 UnitedHealthcare EPO: Choice EPO.
If you enroll in the $3,200 High Deductible Plan, you may be eligible to establish a Health Savings Account. UHS
will fund your Health Savings Account up to an annual contribution of $500 if you have employee only
coverage or $1,000 for you and any covered dependents. See “The Health Savings Account” on page 43 for
more information.
Visit the UHS Benefits Portal and Self-Service Center at https://uhsbenefits.ehr.com for a complete list of
medical options and costs available at your location. Additional options, such as HMOs, may be available. See
the “Alternative Health Plans” section of this SPD on page 47 for more information.

Effective January 1, 2024 16

 Medical

MEDICAL AT A GLANCE
The following charts summarize your benefits under each plan option. For detailed benefit coverage
information, visit the UHS Benefits Portal and Self-Service Center at https://uhsbenefits.ehr.com.

2024 PREFERRED PROVIDER ORGANIZATIONS (PPO)

Most medical options are PPO plans. Our PPO networks are:
 UnitedHealthcare — Choice Plus POS Network • (800) 440-5982 • www.myuhc.com
 BlueCross BlueShield of Tennessee — BlueCard PPO Network • (888) 294-2839 •
www.bcbst.com/members/uhs
 Aetna — Choice POS II Network • (866) 435-7174 • https://www.aetnaresource.com/n/UHS.
These options are not available at all UHS facilities. Check with your Human Resources Department for the
network assignment at your location.

SCHEDULE OF BENEFITS
TYPE OF SERVICE $3,200 HIGH DEDUCTIBLE $1,500 DEDUCTIBLE PLAN $600 DEDUCTIBLE PLAN
HEALTH PLAN
Plan deductible $3,200/person or $1,500/person or $600/person or
(for all covered expenses except $6,400/family $3,000/family $1,200/family
preventive) Per calendar year Per calendar year Per calendar year
Annual out-of-pocket maximum Includes Prescription Drug Includes Prescription Drug Includes Prescription Drug
In-Network $5,000/person, $5,000/person, $5,000/person,
$10,000/family $10,000/family $10,000/family
Out-of-Network None None None
Preventive care 100% coverage, not subject 100% coverage, not subject 100% coverage, not subject
(in-network or UHS facilities only) to plan deductible or to plan deductible or to plan deductible or
copays* copays* copays*
Health Savings Account (HSA) Eligible Not Eligible Not Eligible
Annual Employer Contribution $500/$1,000
UHS facility coinsurance, after deductible
You pay 0% 0% 0%
Plan pays 100% 100% 100%
Network facility coinsurance, after
deductible
You pay 25% 25% 25%
Plan pays 75% 75% 75%
Non-network facility copay $500 after the plan $500 in addition to the $500 in addition to the
(inpatient, outpatient, surgery center) deductible plan deductible plan deductible
Coinsurance, after deductible

Effective January 1, 2024 17

 Medical

TYPE OF SERVICE $3,200 HIGH DEDUCTIBLE $1,500 DEDUCTIBLE PLAN $600 DEDUCTIBLE PLAN
HEALTH PLAN
You pay 50% 50% 50%
Plan pays 50% 50% 50%
Emergency room $200 copayment per visit $200 copayment per visit, $200 copayment per visit,
after deductible, then then 100% after deductible then 100% after deductible
100%
Mental Health/Substance Abuse
facility coinsurance, after deductible for
UHS facility Inpatient and Outpatient
You pay 0% 0% 0%
Plan pays 100% 100% 100%
Mental Health/Substance Abuse
facility coinsurance, after deductible for
in-Network facility Inpatient and
Outpatient
You pay 25% 25% 25%
Plan pays 75% 75% 75%
Mental Health/Substance Abuse
facility coinsurance, after deductible for
Out-of-Network facility Inpatient and
Outpatient
You pay 50% 50% 50%
Plan pays 50% 50% 50%
All other covered expenses (in-network)
Coinsurance, after deductible
You pay 25% 25% 25%
Plan pays 75% 75% 75%
All other covered expenses (out-of-
network)
coinsurance, after deductible
You pay 45% 45% 45%
Plan pays 55% 55% 55%
Prescription drugs – retail 25% after deductible 25% 25%
Up to a 30-day supply: Minimum copays $5 for generics; $15 for preferred brand-name drugs; $30 for non-preferred brand-
name drugs
Prescription drugs – mail order 25% after deductible 25% 25%
Up to a 90-day supply: Minimum copays: $10 for generics; $30 for preferred brand-name drugs; $60 for non-preferred brand-
name drugs

Effective January 1, 2024 18

 Medical

TYPE OF SERVICE $3,200 HIGH DEDUCTIBLE $1,500 DEDUCTIBLE PLAN $600 DEDUCTIBLE PLAN
HEALTH PLAN
Home health care: 120 visits/year
Hospice care: 120 visits/lifetime
PLAN MAXIMUMS
Infertility prescription drug: $10,000/lifetime
Spinal manipulation: 12 treatments/year

* No copayment required for birth control contraceptive devices and certain preventive medications that require a prescription.

2024 EXCLUSIVE PROVIDER ORGANIZATION (EPO)

Some locations offer an EPO plan. If you are in a network area and choose an out-of-network hospital, your
EPO medical plan will not provide coverage. The EPO network is:
 UnitedHealthcare — Choice EPO Network • (800) 440-5982 • www.myuhc.com
This option is not available at all UHS facilities. Check with your Human Resources Department for the network
assignment at your location.

SCHEDULE OF BENEFITS
TYPE OF SERVICE $3,200 HIGH DEDUCTIBLE $1,500 DEDUCTIBLE PLAN $600 DEDUCTIBLE PLAN
HEALTH PLAN
Plan deductible $3,200/person, $1,500/person, $600/person,
(for all covered expenses except preventive $6,400/family per calendar $3,000/family per calendar $1,200/family per calendar
care) year year year
Annual out-of-pocket maximum Includes Prescription Drug Includes Prescription Drug Includes Prescription Drug
In-Network $5,000/person, $5,000/person, $5,000/person,
$10,000/family $10,000/family $10,000/family
Out-of-Network None None None
Preventive care 100% coverage, not 100% coverage, not 100% coverage, not
UHS Facilities subject to plan deductible subject to plan deductible subject to plan deductible
or copays* or copays* or copays*
Local** in-network facility based services
No benefits available No benefits available No benefits available
(except emergency services)
In-network physicians and non-facility
100% 100% 100%
based providers
Non-local in-network facility based services 100% 100% 100%
Health Savings Account (HSA) Eligible Not Eligible Not Eligible
Annual Employer Contribution $500/$1,000
UHS facility coinsurance, after deductible
You pay 0% 0% 0%
Plan pays 100% 100% 100%

Effective January 1, 2024 19

 Medical

TYPE OF SERVICE $3,200 HIGH DEDUCTIBLE $1,500 DEDUCTIBLE PLAN $600 DEDUCTIBLE PLAN
HEALTH PLAN
Local** facility copayments, after No benefits available No benefits available No benefits available
deductible
Non-local in-network facility, after
deductible
You pay 25% 25% 25%
Plan pays 75% 75% 75%
Emergency room $200 copay per visit after $200 copayment per visit, $200 copayment per visit,
deductible, then 100% then 100% after then 100% after
deductible deductible
Mental Health/Substance Abuse
facility coinsurance, after deductible for
UHS facility Inpatient and Outpatient
You pay 0% 0% 0%
Plan pays 100% 100% 100%
Mental Health/Substance Abuse
facility coinsurance, after deductible for
Non-local in-network facility Inpatient and
Outpatient
You pay 25% 25% 25%
Plan pays 75% 75% 75%
All other covered expenses (in-network
physician charges)
You pay 25% 25% 25%
Plan pays 75% 75% 75%
Non-network providers (except for No benefits available No benefits available No benefits available
emergency services)
Prescription drugs – retail 25% after deductible 25% 25%
Up to a 30-day supply: Minimum copays $5 for generics; $15 for preferred brand-name drugs; $30 for non-preferred brand-
name drugs
Prescription drugs – mail order 25% after deductible 25% 25%
Up to a 90-day supply: Minimum copays: $10 for generics; $30 for preferred brand-name drugs; $60 for non-preferred brand-
name drugs
Home health care: 120 visits/year
Hospice care: 120 visits/lifetime
PLAN MAXIMUMS
Infertility prescription drug: $10,000/lifetime
Spinal manipulation: 12 treatments/year

* No copayment required for birth control contraceptive devices and certain preventive medications that require a prescription.
** Local is defined as within 25 miles of a UHS Facility participating in the EPO Plan.

Effective January 1, 2024 20

 Medical

2024 OUT OF AREA PLAN

If you or a dependent live outside a PPO service area, you may be eligible for the Out of Area Plan.
For example, you live in the service area, but your dependent child attends college outside the service area,
the PPO Plan would cover you, but your child would be in the Out of Area Plan.
The Out of Area Plan network is:
 Aetna — Choice POS II Network • 866-435-7174 • https://www.aetnaresource.com/n/uhs.
This option is not available at all UHS facilities. Check with your Human Resources Department for the network
assignment at your location.

SCHEDULE OF BENEFITS
TYPE OF SERVICE $3,200 HIGH DEDUCTIBLE $1,500 DEDUCTIBLE PLAN $600 DEDUCTIBLE PLAN
HEALTH PLAN
Plan deductible $3,200/person, $1,500/person, $600/person,
(for all covered expenses except preventive) $6,400/family per $3,000/family $1,200/family
calendar year per calendar year per calendar year
Annual out-of-pocket maximum Includes Prescription Drug Includes Prescription Drug Includes Prescription Drug
In-Network $5,000/person, $5,000/person, $5,000/person,
$10,000/family $10,000/family $10,000/family
Out-of-Network None None None

Preventive care 100% coverage, not 100% coverage, not 100% coverage, not
subject to plan deductible subject to plan deductible subject to plan deductible
or copays* or copays* or copays*
Health Savings Account (HSA) Eligible Not Eligible Not Eligible
Annual Employer Contribution $500/$1,000
UHS facility coinsurance, after deductible
You pay 0% 0% 0%
Plan pays 100% 100% 100%
Non-UHS facility coinsurance, after
deductible
You pay 25% 25% 25%
Plan pays 75% 75% 75%
Emergency room $200 copayment per visit $200 copayment per visit, $200 copayment per visit,
after deductible, then then 100% after then 100% after
100% deductible deductible

Effective January 1, 2024 21

 Medical

TYPE OF SERVICE $3,200 HIGH DEDUCTIBLE $1,500 DEDUCTIBLE PLAN $600 DEDUCTIBLE PLAN
HEALTH PLAN
Mental Health/Substance Abuse
facility coinsurance, after deductible for UHS
facility Inpatient and Outpatient
You pay 0% 0% 0%
Plan pays 100% 100% 100%
Mental Health/Substance Abuse
facility coinsurance, after deductible for Non-
UHS or Out-of-Network facility Inpatient and
Outpatient
You pay 25% 25% 25%
Plan pays 75% 75% 75%
All other covered expenses (non-UHS or Out-
of-Network)
coinsurance, after deductible
You pay 25% 25% 25%
Plan pays 75% 75% 75%
Prescription drugs – retail 25% after deductible 25% 25%
Up to a 30-day supply: Minimum copays $5 for generics; $15 for preferred brand-name drugs; $30 for non-preferred
brand-name drugs
Prescription drugs – mail order 25% after deductible 25% 25%
Up to a 90-day supply: Minimum copays $10 for generics; $30 for preferred brand-name drugs; $60 for non-preferred
brand-name drugs
Home health care: 120 visits/year
Hospice care: 120 visits/lifetime
PLAN MAXIMUMS
Infertility prescription drug: $10,000/lifetime
Spinal manipulation: 12 treatments/year

* No copayment required for birth control contraceptive devices and certain preventive medications that require a prescription.

COVERAGE LEVELS
When you enroll for coverage under the medical plan, you elect a coverage level based on which of your
dependents you want to enroll. Your coverage level options are:
 employee only
 employee plus spouse
 employee plus child(ren)
 employee plus family.

Effective January 1, 2024 22

 Medical

Your per paycheck deduction for medical plan coverage will depend on which plan option and plan design you
choose and your coverage level. Visit the UHS Benefits Portal and Self-Service Center at
https://uhsbenefits.ehr.com for more information.

ABOUT THE PLAN DESIGN OPTIONS

Depending on your location, you may be able to choose a plan design for your medical plan option. The three
plan designs are not available in all locations.

PREFERRED PROVIDER ORGANIZATION

Under the Preferred Provider Organization, (PPO), you can receive care from any provider:
 If you receive care from a UHS provider, you receive the highest level of coverage. In most cases, the plan
pays the full cost of your care after you meet your annual deductible.
 If you receive care from a network provider, you pay coinsurance equal to 25% of the cost of your care,
after you meet your annual deductible.
 If you receive care from an out-of-network provider, the plan pays reduced benefits. After you meet your
annual deductible and any required copayment, the plan generally covers 50% of the allowed facility
charge or 55% of the allowed physician charge.
UHS and network providers have agreed to charge fees determined by the PPO as reasonable and customary,
which are typically lower than fees charged by out-of-network providers. If you receive care from an out-of-
network provider, you may be balance-billed for the cost of care that exceeds the reasonable and customary
charge.

EXCLUSIVE PROVIDER ORGANIZATION

The Exclusive Provider Organization (EPO) is not offered at all locations. Under the EPO, the plan pays benefits
only for services received at a UHS provider or non-local network provider. If you choose an out-of-network
provider or local network hospital, the plan will not provide coverage:
 If you receive care from a UHS provider, you receive the highest level of coverage. In most cases, the plan
pays the full cost of your care after you meet your annual deductible.
 If you receive care from a non-local network provider, you pay coinsurance equal to 25% of the cost of
your care, after you meet your annual deductible.
 If you are in a network area and receive care at a “local” network hospital, the plan will not pay benefits,
except in the case of an emergency. Local is defined as being within 25 miles of a UHS facility participating
in the EPO plan.
 If you receive care from an out-of-network provider, the plan will not pay for benefits, except in the case
of an emergency.

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OUT OF AREA PLAN

If you or your dependent live outside of PPO service area, you may be eligible for the Out of Area Plan, if
available. For example, if your dependent child attends college outside of the PPO service area, you may be
covered under the PPO while your child is covered under the Out of Area Plan.
Under the Out of Area Plan, you can receive care from any provider:
 If you receive care from a UHS provider, you receive the highest level of coverage. In most cases, the plan
pays the full cost of your care after you meet your annual deductible.
 If you receive care from a non-UHS provider, the plan generally covers 25% of the cost of your care, after
you meet your annual deductible. You may be balance billed for the cost of care that exceeds the
reasonable and customary charge.

HOW THE PLAN PAYS BENEFITS

The following describes how the plan pays benefits. For detailed benefit coverage information, visit the UHS
Benefits Portal and Self-Service Center at https://uhsbenefits.ehr.com.

DEDUCTIBLE
For most expenses, you will have to pay out of pocket before the plan pays benefits. This amount is called the
“deductible.” If you are employed at a UHS location in a PPO service area, additional deductibles and
coinsurance may apply when you use an out-of-network provider. Refer to the Schedule of Benefits in
“Medical at a Glance” on page 17.

CALENDAR YEAR DEDUCTIBLE

The calendar year deductible is reflected in your Schedule of Benefits (see “Medical at a Glance” on page 17).
This deductible has features that limit the amount you have to pay:
 Family Deductible: Once you and other members of your family satisfy the deductible amount reflected in
the Schedule of Benefits, under Family, the deductible for all covered members will be satisfied for that
year. See “Medical at a Glance” on page 17.
 Carryover Deductible: Although a new deductible normally applies for each calendar year, any covered
charges you use to satisfy the deductible during the last three months of the year may also be used to
satisfy your deductible for the following year. This does not apply to the High Deductible Health Plan nor
the family deductible in all plans.

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The one exception to the application of a deductible is that eligible preventive care services received through a
UHS provider or a network provider are covered in full without the need to first meet your deductible.

COINSURANCE AND COPAYMENTS

Depending on your plan option, plan design and where you choose to receive care, you and the plan may
share in the cost of your coverage through coinsurance and copayments:
 Coinsurance is a percentage of the reasonable and customary charge that you are responsible for paying
for covered services.
 Copayment is a set dollar amount that you are responsible for paying for covered services.
See “Medical at a Glance” on page 17 for more information about the coinsurance and copayments for
covered services under your plan option and plan design.

REASONABLE AND CUSTOMARY CHARGE

The medical plan pays benefits for charges that are reasonable, customary and necessary. Allowed charges are
based on participating provider contracted rates. For non-participating providers, allowed charges are based
on a “reasonable and customary” rate. Reasonable and customary means the usual, average expenses charged
in your locality for services and supplies that are medically necessary for the treatment of a particular
condition. Reasonable and customary determinations may vary from carrier to carrier. Necessary means that
the procedure, service, or supply used to treat a disease or injury must be medically required and accepted
within the medical profession as the usual, customary, and effective means of treating the disease or injury.
Contact your carrier for additional information.

NO MAXIMUM LIFETIME BENEFIT

There is no overall plan lifetime maximum dollar limit on benefit payments.

ANNUAL OUT-OF-POCKET MAXIMUM

The plan limits the amount you have to pay each year for medical expenses. You reach the annual out-of-
pocket maximum when you meet your deductible and your coinsurance payments meet your plan’s annual
out-of-pocket maximum for one covered person, or for a family. After that, the plan pays 100% for that
individual for the remainder of that year. If you are employed at a UHS location in a PPO service area, plan
deductibles and coinsurance are not counted toward the out-of-pocket maximum when you use out-of-
network services, and benefits will continue to be subject to the plan deductible and coinsurance for out-of-
network services.

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MAXIMUM OUT-OF-POCKET EXPENSE

The medical plan has an additional provision that limits the amount you have to pay out of your own pocket
for medical expenses. After you have paid the deductible, or if no deductible applies, the plan pays benefits
according to the coinsurance indicated in the Schedule of Benefits. You pay your coinsurance until your
coinsurance and your deductible, if any, reaches the Maximum Out-of-Pocket Expense reflected in the
Schedule of Benefits in a calendar year for one covered person, or for a family. After that, the plan pays 100%
for that individual for the remainder of that year.
This plan has an embedded Maximum Out-Of-Pocket limit. Once you or a covered dependent reach the
individual out-of-pocket maximum, the plan pays 100% of that person's eligible expenses for the rest of the
calendar year. Once your family out-of-pocket maximum is reached, the plan pays 100% of eligible expenses
for the rest of the calendar year for all covered individuals.
If you are employed at a UHS location in a PPO service area, plan deductibles and coinsurance are not counted
toward the out-of-pocket maximum when you use out-of-network services, and benefits will continue to be
subject to the plan deductible and coinsurance for out-of-network services. See “Medical at a Glance” on
page 17 for the Schedule of Benefits applicable to your coverage.

PRE-ADMISSION CERTIFICATION/CONCURRENT REVIEW

Most hospital admissions must be approved in advance. If approval is not obtained, payment will be less than
the amount otherwise payable. More information on the utilization review program is available from your
insurance carrier. The decision to obtain medical services is between you and your physician regardless of the
plan benefits available.

PRIOR AUTHORIZATION
The medical claim administrator may use vendors to obtain additional information from you related to your
claims, overpayments and required precertification of services. If you are contacted for information related to
your medical claims or precertification of services and have questions, you can contact Member Services at
the number on the back of your ID card for additional information. Please refer to your carrier’s Evidence of
Coverage (EOC) for specific information regarding out-of-network providers that may impact your claim.

SPECIAL RIGHTS FOR MOTHERS AND NEWBORN CHILDREN

Under this medical plan, a hospital length of stay in connection with childbirth for the mother or a newborn
child will not be restricted to less than 48 hours following a normal vaginal delivery, or less than 96 hours
following a cesarean section. However, the mother’s or newborn’s attending provider, after consulting with
the mother, may discharge the mother or her newborn earlier than 48 hours (or 96 hours, as applicable) after
the delivery. In any case, no authorization is required from the Plan or an insurance company for a length of

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stay that does not exceed 48 hours (or 96 hours). However, approval must be obtained for maternity
admissions in excess of the days indicated above.

WHAT’S COVERED
The plan pays benefits for the following services.

TELEHEALTH
For non-emergency situations, the telehealth program provides confidential access to health care and
behavioral health professionals 24 hours a day, seven days a week by phone, online video or mobile app.
Contact a doctor any time, day or night, from home or when you’re away from home.
Use telehealth when:
 you need care or health information and your primary doctor isn’t available or it’s after normal business
hours
 you are considering the ER or urgent care for a nonemergency issue
 you are away from home
 you need a short-term prescription refill.
Telehealth can help treat many medical conditions, including, but not limited to:
 allergies, cold, fever and flu
 skin conditions, such as rashes or insect bites
 earaches
 nausea, vomiting and other stomach distress concerns.
Visit the UHS Benefits Portal and Self-Service Center at https://uhsbenefits.ehr.com to find out about covered
services, your cost for a telehealth visits and the telehealth provider in your network. You should also contact
your insurance carrier for more details as to what diagnoses are covered under the telehealth program.

HOSPITAL EXPENSE BENEFITS

Inpatient room and board at the semi-private room rate is covered by the plan after you satisfy the calendar
year deductible. If you occupy a private room during your stay, the plan will consider the hospital's average
semi-private room charge and you will be responsible for charges in excess of the semi-private room rate.
Charges for use of a surgical day unit or outpatient facility charges for surgery are payable according to the
same percentage and deductible applied to inpatient services. Other charges for emergency room and
outpatient medical care are covered by the plan. No deductible is applied to these charges if they are due to
an emergency admission or to re-confinements within three months for the same diagnosis

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Other covered hospital charges are:

 charges for necessary services and supplies
 charges for drugs and medicine
 charges for blood, blood plasma and its administration
 X-ray and lab services
 X-ray, radium, and radioactive isotopic therapy.

SURGICAL EXPENSE BENEFITS

If you or your covered dependent undergoes a surgical operation while confined in a hospital, or on an
outpatient basis, the plan will pay benefits according to your plan option and plan design, based on reasonable
and customary charges for the surgery. Your coinsurance is paid by you after the deductible is met and is
counted toward your annual out-of-pocket maximum.
Related doctor, surgeon, or assistant surgeon charges are also covered surgical expenses.
 Because UHS recognizes the importance of your decision regarding surgery, the plan will pay 100% of
reasonable and customary charges for the cost of obtaining a second or third opinion for an elective
surgical procedure, not subject to a deductible. NOTE: The deductible and coinsurance will continue to
apply in the High Deductible Health Plan.

PREVENTIVE CARE BENEFIT

If you or a covered dependent obtains services in connection with preventive healthcare, including preventive
care medications and birth control medications and devices, the plan will pay 100% of covered charges. This
coverage is in accordance with recommended screenings of the U.S. Preventive Services Task Force.
Benefits for preventive care are only available when provided by a network provider or UHS provider unless
you are enrolled in the Out of Area PPO Plan. Further restrictions on covered providers may apply if you are
enrolled in the EPO Plan.
Preventive care benefits do not include charges relating to diagnosis or treatment of an illness or injury or
charges incurred for a medical exam to obtain insurance, a job or continue employment. For more information
about covered preventive services, visit your carrier’s website.

BREAST CANCER SCREENING

Breast cancer screening is covered at 100%, with no deductible or copay, when provided by a UHS or network
provider. Coverage may be limited under the EPO Plan. Benefits may include traditional film or digital
mammography. Coverage is in accordance with recommended screenings of the U.S. Task Force for Preventive
Care.

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Women at high risk of breast cancer, including women with known BRCA1 and BRCA2 gene mutation, may
qualify for screening at a younger age than recommended, if medically indicated. Women at high risk may
qualify for MRI screening and/or ultrasonography, if deemed medically indicated. Women over age 80 should
consult with their physician to determine if it is necessary to continue screenings.

MAJOR MEDICAL BENEFITS

Covered expenses include the following:
 hospital outpatient and emergency room charges
 doctor's professional services
 diagnostic X-ray and laboratory services
 X-ray and radioactive therapy
 anesthesia and its administration
 oxygen and its administration
 rental or purchase of durable medical equipment, whichever is less
 artificial limbs and artificial eyes
 foot orthotics (prescription required)
 inoculations except for the purposes of travel
 professional ambulance service, except air ambulance (paid in life threatening situations and transport
must be to the nearest facility able to treat the injury or illness)
 oral surgery including:
 wisdom teeth extraction for impacted and non-impacted teeth when performed by an oral surgeon
 other extractions, incisions, and surgical and repair procedures
 education for diabetes, cardiac, and renal care
 diabetic supplies, such as lancets and test strips when purchased through a CVS Caremark participating
pharmacy or CVS Caremark mail-service
 diabetes self-management equipment and devices based on medical need, such as insulin pumps and
blood glucose monitors
 nutritional counseling
 obesity surgery
 transplantation services (inpatient facility services, including evaluation for transplant, organ procurement,
donor costs that are directly related to organ removal, and donor searches) that are ordered by a network
provider, unless patient is covered by the Out of Area Plan

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 travel and lodging related to congenital heart disease and transplantation services (patient must be
receiving services at network facility unless patient is covered by the Out of Area Plan)
 genetic testing and counseling for individuals and families who have a genetic disease or who are at risk for
such a disease (examples include, but are not limited to, testing for down syndrome, sickle cell anemia,
and breast and ovarian cancers)
 acupuncture
 cochlear implant surgery
 hearing aids, including any tests, appliances and devices to improve hearing or enhance other forms of
communication to make up for hearing loss or devices that simulate speech when medically necessary
 hearing exams performed to evaluate and treat illness, injury or hearing loss, when medically necessary.

HOME HEALTH CARE

The plan pays benefits for eligible home health care services for up to 120 visits per year, including:
 charges for a licensed practical nurse or registered nurse, other than a family member who resides in your
home
 part-time home health aide services
 physical therapy, occupational therapy, and speech therapy
 charges for prescription drugs
 other medical services and supplies on an outpatient basis.
The plan pays for a maximum of 120 visits by registered graduate nurses, licensed practical nurses, or
therapists each year. The services must be medically necessary and not considered primarily custodial in
nature.

HOSPICE CARE
Hospice benefits are available if you are terminally ill and if life expectancy is determined by a physician to be
six months or less. The lifetime maximum benefit for hospice care is 120 days. When rendered directly by the
hospice agency, covered services include:
 inpatient hospice care
 physician services
 skilled nursing and nursing aide visits
 physical, occupational and speech therapy
 bereavement services
 respite care

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 drugs and medications

 home health care services
 social worker visits to evaluate support system, financial issues and community resources.

INFERTILITY TREATMENT
The plan covers basic and comprehensive infertility services:
 basic services to diagnose and evaluate the underlying medical cause and surgery to treat the underlying
cause, such as endometriosis or varicocele
 comprehensive services through a network infertility specialist including six cycles of ovulation induction
while on injectable medication to stimulate the ovaries and artificial insemination (six cycles of
intrauterine /intracervical insemination).
You are eligible for infertility treatment services if:
 you or your partner have been diagnosed with infertility
 you have met the requirements for the number of months trying to conceive through egg and sperm
contact
 your unmedicated day 3 Follicle Stimulating Hormone (FSH) level and testing of ovarian responsiveness
meet your carrier’s policy.
Coverage for infertility treatment may include either a dollar or cycle limit; contact your carrier for more
information. For plans with cycle limits, a cycle is:
 an attempt at ovulation induction while on injectable medication to stimulate the ovaries with or without
artificial insemination
 an artificial insemination cycle with or without injectable medication to stimulate the ovaries.

SPINAL MANIPULATION
The plan pays a maximum of 12 treatments per calendar year for spinal manipulation. The services must be for
the treatment of an illness or injury and not primarily as maintenance therapy or preventive care.

MENTAL HEALTH/SUBSTANCE ABUSE BENEFITS

If you or a covered dependent is confined in a hospital or residential treatment center for mental health or
substance abuse treatment, the plan generally pays benefits on the same basis as any other medical condition.
Outpatient treatment, such as office with a psychologist or psychiatrist, are also covered under the plan. See
“Medical at a Glance” on page 17 or contact your carrier for more information.

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WOMEN'S HEALTH AND CANCER RIGHTS ACT

The Plan will provide certain coverage for benefits received in connection with a mastectomy, including
reconstructive surgery following a mastectomy. This benefit applies to any covered employee or dependent,
including you, your spouse, and your dependent children.
If the covered person receives benefits under the Plan in connection with a mastectomy and elects breast
reconstruction, the coverage will be provided in a manner determined in consultation with the attending
physician and the covered person. Coverage may apply to:
 Reconstruction of the breast on which the mastectomy was performed;
 Surgery and reconstruction of the other breast to produce a symmetrical appearance;
 Prostheses; and
 Treatment of physical complications at all stages of the mastectomy, including lymphedemas.
Benefits for breast reconstruction are subject to annual Plan deductibles and coinsurance provisions that
apply to other medical and surgical benefits covered under the Plan.

WHAT’S NOT COVERED

The medical plan will not pay benefits for:
 charges which exceed the reasonable and customary charges
 anything not medically necessary for treatment of illness or injury except as specified in the plan
 services or supplies required to treat an occupational injury or disease
 services furnished because of injury or illness caused by an act of war, declared or undeclared, or from
military service
 services furnished or paid for by the federal or state government, except for a plan established for its own
civilian employees or their dependents
 services for treatment not recommended or approved by a physician
 charges for eye exams, glasses or contact lenses
 cosmetic surgery and related medical/surgical expenses unless medically necessary due to an accident or
congenital anomaly in a newborn or newly adopted child
 charges which would not have been made if no coverage existed or for which there is no legal liability to
pay
 charges for custodial care or routine care, including routine foot care
 any claim filed more than one year from the service date
 any charges for services or supplies which are experimental, investigational, or unproven, or not provided
in accordance with accepted professional medical standards

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 admissions or medical or surgical services for weight control unless there is a diagnosis of morbid obesity
and the surgery is specifically covered as obesity surgery
 physical, occupational, or other rehabilitative therapy unless it is to restore or improve any lost or
impaired bodily function or for the treatment of autism, including Applied Behavioral Analysis
 speech therapy, except when required for treatment of a speech impediment or speech dysfunction that
results from Autism, Injury, Sickness, stroke, cancer or a congenital anomaly, or is needed following the
placement of a cochlear implant.
 charges for dental expenses, except as specifically provided for under this plan
 infertility services associated with or in support of an Advanced Reproductive Technology (ART) cycle.
These include, but are not limited to:
 imaging, laboratory services, and professional services
 in vitro fertilization (IVF)
 zygot intrafallopian transfer (ZIFT)
 gamete intrafallopian transfer (GIFT)
 cryopreserved embryo transfers
 any related services, products or procedures (such as intracytoplasmic sperm injection (ICSI) or ovum
microsurgery).
 other infertility service and procedures that are not covered include:
 cryopreservation (freezing), storage or thawing of eggs, embryos, sperm or reproductive tissue
 charges associated with or in support of surrogacy arrangements for you or the surrogate. A surrogate
is a female carrying her own genetically related child with the intention of the child being raised by
someone else, including the biological father
 home ovulation prediction kits or home pregnancy tests
 the purchase of donor embryos, donor eggs or donor sperm
 obtaining sperm from a person not covered under this plan
 infertility treatment when a successful pregnancy could have been obtained through less costly
treatment
 infertility treatment when either partner has had voluntary sterilization surgery, with or without
surgical reversal, regardless of post reversal results. This includes tubal litigation, hysterectomy and
vasectomy only if obtained as a form of voluntary sterilization
 reverse sterilization
 infertility treatment when infertility is due to a natural physiologic process such as age-related ovarian
insufficiency (such as perimenopause or menopause) as measured by an unmedicated FSH level at or
above 19 on cycle day two or three of your menstrual period
 treatment for dependent children

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 injectable infertility medication, including but not limited to menotropins, hCG and GnRH agonists.
 circumcision unless medically indicated
 professional services performed by a person who ordinarily resides in your household or is related to the
covered person, such as a spouse, parent, child, brother, sister, or in-law
 expenses incurred as the result of an auto accident up to the amount of any state-required automobile
insurance with respect to those expenses
 a service or supply resulting from participation in or attempt to commit an assault, felony, or participation
in an act of civil disturbance or riot
 charges resulting from penalties, exclusions, or charges in excess of allowable limits imposed by any
provider resulting from failure to follow the required procedures for obtaining services or treatment
 educational services, counseling, or job training for learning disorders
 nutritional supplements, such as TPN therapy, except when such therapy is the only means of nutrition or
is specifically created to treat an inborn error of metabolism such as PKU (phenylketonuria)
 medical supplies obtainable without a prescription, except for diabetic supplies such as lancets and test
strips when purchased at a CVS Caremark participating pharmacy or through CVS Caremark’s mail-service
 prescription drugs not purchased at a CVS Caremark participating pharmacy or through CVS Caremark’s
mail-service
 travel or transportation expenses, even if ordered by a physician, except as identified under travel and
lodging as a covered expense under “Major Medical Benefits” on page 29
 services for evaluation and treatment of temporomandibular joint syndrome (TMJ)
 treatment for benign gynecomastia (abnormal breast enlargement in males)
 surgery and related treatment to correct nearsightedness, farsightedness, presbyopia, and astigmatism
including, but not limited to, laser and other refractive eye surgery and radial keratotomy
 services for child(ren) of covered dependents, unless you have assumed legal guardianship (including
newborns)
 immunization for the purpose of travel.

PRESCRIPTION DRUG COVERAGE

The plan covers prescription medications filled at CVS Caremark participating network pharmacies for up to
one 30-day supply, plus one grace refill. The plan will also cover prescriptions filled for up to a 90-day supply
when the prescription is filled:
 at a CVS retail pharmacy
 through the CVS Caremark Mail Service Pharmacy, where available.
When you purchase prescription drugs at CVS Caremark participating pharmacies, you will receive up to one
30-day supply plus one grace refill of medication for the plan coinsurance amount, without a deductible,

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except under the $3,200 High Deductible Plan. When you use the mail-service feature, you receive up to a 90-
day supply of medication for the plan coinsurance amount, without a deductible-except under the $3,200 High
Deductible Plan. See “Medical at a Glance” on page 17 for applicable coinsurance and co-pay minimums. You
or your physician may contact CVS Caremark to initiate a 90-day supply for your maintenance medication, if
available.
Important: You must use the mail-service feature for your maintenance medications; otherwise, your
prescription drugs will not be covered except for one initial 30-day supply purchased at a CVS Caremark
participating pharmacy plus one grace refill. After the grace refill, claims for maintenance medications will be
denied at a participating network retail pharmacy and will only be covered by filling your prescription through
the CVS Caremark Mail Service Pharmacy.
Your prescription drug purchases count toward your annual out-of-pocket maximum. See “PrudentRx
Program” on page 36 for more information about your annual out-of-pocket maximum related to specialty
drug prescriptions.
There is no deductible or coinsurance payment required for the following:
 Birth control or contraceptive devices that require a prescription.
 Certain preventive care medications as defined in the prescription drug plan.
 Specialty drugs included on the PrudentRx Program Drug List when enrolled in the PrudentRx Program. See
“PrudentRx Program” on page 36 for more information.
Please note:
 There is no reimbursement for purchases made from a nonparticipating pharmacy.
 If you purchase a brand-name medication when a generic drug is available, you will pay the plan
coinsurance for the generic drug plus the full difference in cost between the brand name and the generic
drug.
 You may be required to try a generic substitute before taking certain brand medications, and certain
brands may no longer be covered under the prescription plan.
 See the CVS Caremark prescription benefit packet that was mailed to you for more information on the
mail-service prescription feature.
 The prescriptions that are prescribed for you by your doctor may be subject to certain limitations whether
purchased through CVS Caremark or considered for benefits under your medical plan. Prescribed
medications need to meet certain medical criteria to be approved for benefits (prior authorization), may
be subject to treatment guidelines that recommend trying an alternative therapy first (step-therapy), may
be excluded under the Plan’s Formulary, subject to quantity limits and/or require administration in a
certain setting (e.g., in a doctor’s office). Talk to your doctor and check with CVS Caremark or your medical
plan for coverage guidelines.

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PRUDENTRX PROGRAM
 CVS Caremark prescription coverage includes the PrudentRx Program for certain specialty medications.
This program reduces your out-of-pocket costs by helping you enroll in drug manufacturer copay
assistance programs for eligible specialty medications. Here’s how the program works:
 When you participate in the PrudentRx Program, your out-of-pocket cost will be $0 for specialty
medications included on the PrudentRx Program Drug List, available at
https://www.prudentrx.com/prudentes/. If you are enrolled in the HDHP and your medication is included
on the HDHP Preventive Drug List (see the PrudentRx Program Drug List for more information), your out-
of-pocket cost will be $0 for specialty medications. For all specialty medications listed on the PrudentRx
Program Drug List, but not included on the HDHP Preventive Drug List, your out-of-pocket cost will be $0
after you have met your annual deductible.
 If you take one or more eligible specialty medications, you will receive a welcome letter and phone call
from PrudentRx providing more information about the program or you can contact PrudentRx directly at
(800) 578-4403. If you do not respond to PrudentRx communications or outreach, choose to opt out, or do
not enroll in any copay assistance program required by the manufacturer of your specialty medication, you
will pay 30% coinsurance on specialty medications that are eligible under the PrudentRx Program (see the
PrudentRx Program Drug List).
 Payments made on your behalf, including amounts paid by a manufacturer’s copay assistance program, for
medications covered under the PrudentRx program will not count toward your plan deductible (for those
not enrolled in an HDHP) or out-of-pocket maximum, unless otherwise required by law. Also, payments
made by you for a medication that does not qualify as an “essential health benefit” under the Affordable
Care Act, will not count toward your deductible (for those not enrolled in an HDHP) or out-of-pocket
maximum, unless otherwise required by law.

SPECIALTY DRUG MANUFACTURER COPAY ASSISTANCE PROGRAMS

These programs, offered by manufacturers directly to consumers, often include coupons for a specific value or
“loaded” debit card presented at point of sale (such as a pharmacy or doctor’s office). Plan members who use
third party copayment assistance programs for certain Specialty Medications, or are enrolled in the PrudentRx
Program, will not receive credit toward the plan’s out-of-pocket maximum or deductible for any amounts that
are applied to manufacturer coupons or rebates.
There is a $10,000 lifetime maximum benefit for prescription drugs related to enhancing fertility or increasing
the likelihood of conception.

GENERAL PLAN PROVISIONS

The following describes general provisions of the plan. Some states may require that CVS Caremark modify the
general plan provisions for its state residents. If any changes apply to your prescription drug benefits, CVS

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Caremark will allow for any such required changes. For specific information about plan provisions for your
plan, visit the UHS Benefits Portal and Self-Service Center at https://uhsbenefits.ehr.com.

COORDINATION OF BENEFITS
When you or your covered dependent(s) are eligible for benefits under another group plan, one of the plans
involved will pay first – the primary plan – and the other plan(s) will be secondarily liable for the payment of
benefits – the secondary plan(s). The primary plan pays benefits first in accordance with its terms, without
consideration of the other plans or their terms.
For the purposes of understanding how UHS coordinates benefits with other plans, the following terms have
specific meaning:
 plan: Group insurance or group-type coverage, whether insured or uninsured. This includes health
maintenance, prepayment, group practice or individual practice coverage. It also includes coverage other
than school accident-type coverage and coverage under a governmental plan, coverage required or
provided by law or an automobile insurance policy. This does not include a state Medicaid Plan (Title XIX,
Grants to States for Medical Assistance Programs, of the United States Social Security Act). Note: failure to
disclose that you have coverage under another group medical plan constitutes falsifying a record and is a
crime.
 primary plan: A benefit plan that has primary liability for a claim.
 secondary plan: A benefit plan that adjusts its benefits by the amount payable under the primary plan.
 non-duplication of benefits: The method under which this plan coordinates benefits with other plans.
Under non-duplication of benefits, this plan will pay either its regular benefit in full or a reduced amount
that, when this plan is secondary to another group benefit plan's coverage, will not be more than the full
benefit provided by this plan. When this plan is secondary and your primary plan’s benefit is equal to or
more than what this plan would pay on a primary basis, no benefits would be paid by this plan. Charges
paid by the primary plan but not covered by this plan are not reimbursable, even at the reduced amount.
 longer-shorter rule: A rule used to determine which plan is primary versus secondary. Under this rule,
benefits of the plan that covered the person for the longer period of time are determined before those of
the plan covering that person for the shorter period of time.
The following table outlines how benefits are determined. Reading from top to bottom, the first rule that
applies to your situation determines which is the primary plan and which is the secondary plan. If none of the
following rules apply, the longer-shorter rule will be used to determine benefits. In addition, if these rules do
not establish the order of payment in your situation, the allowable expenses will be shared equally between
the plans, with this plan not paying more than it would have paid had this plan been primary.
When the claim is for … The Primary Plan is … The Secondary Plan is …
A participant in this plan and a plan The other plan This plan
without coordination of benefits rules

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 Medical

When the claim is for … The Primary Plan is … The Secondary Plan is …
You The plan covering you as an active The plan covering you as a retiree, laid
employee off employee or dependent

You, when: Your auto liability or no-fault insurance This plan

 Your claim is covered under policy
your auto liability coverage
 Your claim is covered under
your no-fault insurance policy
A child and the parents are married or  The plan of the parent whose  The plan of the parent whose
living together birthday (month and day) is earlier birthday is later in the year
in the year (Birthday Rule)  If both parents have the same
 If both parents have the same birthday (month and day), the plan
birthday (month and day), the plan that has covered a parent the
that has covered a parent for the shortest period of time
longest period of time
A participant with coverage under The plan covering the participant as an The plan covering the participant under
COBRA or state-continuation of UHS employee or retiree (or dependent of an COBRA or state- continuation of UHS
coverage and has coverage under employee or retiree) coverage
another plan as an employee or retiree

It’s important to understand how the plan coordinates benefits when you are enrolled in Medicare. If the plan
covering you as a dependent is primary to Medicare and the plan covering you as an employee is secondary to
Medicare, the plan covering you as a dependent will pay first, Medicare pays second and the plan covering
you as an employee pays third.
Note: When a child’s parents are separated, divorced or not living together, the primary plan is the plan of the
parent responsible for health coverage under a court order and the plan has knowledge of those terms. If the
court order states that both parents are responsible for the dependent child’s health care coverage and have
joint custody, but doesn’t state which parent is responsible for the child’s health coverage, benefits will be
determined under the Birthday Rule. If there is no court order specifying which parent is responsible for health
coverage, benefits are determined in this order:
1. the plan of the parent with custody of the child, then
2. the plan of the spouse of the parent with custody of the child (such as a stepparent), then
3. if the parent with custody does not have health coverage, the plan of the parent without custody of the
child, then
4. the plan of the spouse of the parent without custody (such as a stepparent).
For a dependent child covered under more than one plan of individuals who are not the parents of the child,
benefits are determined under the rule for a child living with parents who are married and living together (see
the table beginning on page 37).

Effective January 1, 2024 38

 Medical

Please refer to your carrier’s Evidence of Coverage (EOC) for specific information regarding coordination of
benefits rules that may impact your claim.

ASSIGNMENT OF RIGHTS (SUBROGATION) AND THE RIGHT OF RECOVERY

By accepting benefits from the Plan, you and your covered dependents automatically assign to the Plan any
rights you or they may have to recover benefits paid on behalf of you or your covered dependents from
another source, including another group health plan, insurer or individual, up to the amount the Plan has paid.
This assignment also grants the Plan a right to recover from your no-fault auto insurance carrier in a situation
where no third party may be liable, and from any uninsured or underinsured motorist coverage.

Plan Rights
The Plan is entitled to recover 100% of the amounts paid, or to be paid, by the Plan on behalf of you or your
covered dependents from all recoveries by you or your covered dependents from any other party (whether by
lawsuit, mediation, arbitration, settlement, award, judgment, order, insurance or otherwise). This includes,
without limitation, a right to any funds paid by any other party to you or your covered dependents.
This assignment of rights also allows the Plan to pursue any claim that you or your covered dependents may
have against any third party, or its insurer, whether or not you or your covered dependent choose to pursue
that claim.
The Plan reserves all rights to seek enforcement of its rights including, but not limited to, the right to file a
lawsuit against you or your covered dependent or any other party possessing or controlling any funds, and the
right to recoup amounts owed in any other manner prescribed by law.

Participant Agreements and Requirements

By accepting benefits from this Plan, you agree that the Plan has established an equitable lien against any
money or property you or your covered dependents (or any individual or entity acting on your or their behalf
such as a legal representative or agent) recover from any other party. The Plan’s lien exists at the time the
Plan pays benefits, and if you or your covered dependents file a petition for bankruptcy, you and your covered
dependents agree that the Plan’s lien existed prior to the creation of the bankruptcy estate. You further agree
to hold any reimbursement or recovery received by you or your covered dependents (or any legal
representative or agent) in trust on behalf of the Plan to cover all benefits paid by the Plan.
You and your covered dependents are required to cooperate with efforts to recover benefits paid under the
Plan. This cooperation includes providing relevant information, providing the identity of any other person or
entity and their insurers, if applicable, that may be obligated to provide payments or benefits on account of
the same illness or injury for which the Plan made payments, signing and delivering documents the Plan
reasonably requests, and obtaining the Plan’s consent before releasing any party from liability. If you enter

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 Medical

into litigation or settlement negotiations regarding the obligations of other parties, you must not prejudice, in
any way, the Plan’s subrogation and reimbursement rights.
When you or your covered dependents – and not the Plan – pursue and recover funds, you or your covered
dependents are responsible for all expenses involved in obtaining that recovery (whether obtained by lawsuit,
mediation, arbitration, settlement, award, judgment, order, insurance or otherwise), including but not limited
to, attorneys’ fees, costs, and expenses. These fees, costs, and expenses will not reduce the amount that you
or your covered dependents are required to reimburse the Plan, and the Plan’s rights will not be reduced due
to your or your covered dependent’s negligence. You and your covered dependents must also notify the Plan
Administrator within 45 days of the date you notify a third party that you intend to recover damages due to
your or your covered dependent’s illness or injury.
You and your covered dependents are required to reimburse the Plan on a first-dollar basis (which means that
the Plan will have a first priority claim to any recovered funds), regardless of how they are characterized (e.g.,
pain and suffering, punitive damages, benefits, lost wages, loss of future earnings, medical expenses, costs
and/or expenses, attorneys’ fees) and regardless of whether the recovery is designated as payment for
medical services or expenses. The Plan’s share of the recovery will not be reduced because you or your
covered dependent has not received the full damages claimed, unless the Plan agrees in writing to a
reduction. Any reduction is subject to prior written approval by the Plan.
Failure by you or your covered dependents to cooperate with the Plan may result, at the discretion of the
Plan, in a denial or reduction of future benefit payments available to you or your covered dependents under
the Plan.
The Plan’s provisions concerning subrogation/right of recovery, equitable liens, and other equitable remedies
(outlined above and more fully below) supersede the applicability of the federal common law and equitable
doctrines commonly referred to as the “make whole” rule, the “double-recovery” rule and the “common
fund” rule. These doctrines have no applicability to the Plan’s right of recovery hereunder.

TERMS
The terms define important words used in this SPD. The meaning of each defined word, whenever it appears
in this SPD, is governed by its definition as listed below.

PHYSICIAN/DOCTOR
The term physician/doctor as used in the plan means a person who is:
 either a Doctor of Medicine, Doctor of Osteopathy, Doctor of Dentistry, Doctor of Chiropractic, Doctor of
Podiatry, or Clinical Psychologist
 licensed to practice medicine
 any licensed medical practitioner or counselor if practicing within the scope of his/her license and
performing a service for which benefits are provided under this plan when performed by a physician

Effective January 1, 2024 40

 Medical

 not a member of your immediate family or your covered dependents' family.

The term physician/doctor does not include a Christian Science Practitioner or any other person not included
above.

HOSPITAL
The term hospital means a legally operated hospital under the supervision of a staff of physicians/doctors,
with 24-hour service and facilities for diagnosis and major surgery. (Any institution, or part of it, which is used
primarily as an extended-care facility, or for training, custodial, or convalescent purposes is excluded.) The
hospital must be approved by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). In
the case of hospitals outside the United States where JCAHO accreditation does not apply, the services
provided must be of an emergency nature or for extraordinary circumstances to be determined by the Plan
Administrator. The following facilities, if licensed, shall also qualify as a "hospital":
 rehabilitation or chronic disease hospital
 residential treatment center
 birthing center
 freestanding surgical center.

HOME HEALTH CARE AGENCY

A home health care agency is either primarily engaged in, or licensed to, provide skilled nursing services and
other therapeutic services under the full-time supervision of a physician or registered graduate nurse and an
administrator. A professional group, including at least one physician and one registered graduate nurse, must
establish policies, and complete medical records must be maintained for each patient.

HOSPICE AGENCY
A hospice agency is a facility which is staffed and equipped to:
 provide care, either in the home or in the facility, or both, for persons who are terminally ill and do not
want or require the full services of a hospital or skilled nursing facility;
 offer medical services under the direction of a physician with a staff of professional nurses available 24
hours a day; and
 provide, directly or by arrangement, social, psychological, or spiritual services for the patient and for the
patient's family.

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 Medical

TOTALLY DISABLED
Totally disabled means a condition resulting from an illness or injury that prevents you or your dependent
from working or performing activities of other healthy people of the same education, training and experience.

CLAIMS
Use this information to file claims for benefits under the plan.

WHEN TO FILE A CLAIM

A claim form must be filed for each claim on each person covered by the plan.
You must file a claim for medical expenses which are covered by the medical plan within one year from the
service date. Network providers typically file the claim on your behalf. However, it is your responsibility to
ensure your claim has been filed.

HOW TO FILE A CLAIM

If you must file a claim, obtain a claim form from your medical plan claims administrator:
 For Aetna, call (866) 435-7174 or visit https://www.aetnaresource.com/n/UHS
 For BlueCross BlueShield of Tennessee (BCBS), call (888) 294-2839 or visit www.bcbst.com/members/uhs
 For United HealthCare (UHC), call (800) 440-5982 or visit www.myuhc.com.
Refer to the back of your ID card for the address for submitting claims.
Complete the form making sure to answer all questions completely and sign the form.
You must attach the doctor's form or bill, which must include the following:
 name of patient,
 date, charges, and description of each service, and
 diagnosis.
Your provider may submit a claim directly for you.

PAYMENT OF A CLAIM
Once the claims administrator receives a properly completed claim, it will be processed for payment. Payment
will be made to you unless you authorize direct payment to the provider or person furnishing services.
In addition, if you die before benefits are paid, payment will be made to your estate.

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 Medical

IF A CLAIM IS DENIED
If your claim is denied, in whole or in part, you will receive a statement from the claims administrator
explaining the exact reasons the claim has been turned down. However, if you still feel your claim was unfairly
denied, you have certain rights under federal law.
In order to process your claims, it may be necessary to obtain medical records from your providers or other
sources. By accepting coverage under this plan, you agree that the claim administrator may have access to the
additional information. All information will be kept strictly confidential.
For additional information, refer to “Health Claim Filing and Appeal Procedures” on page 169 in the “Plan
Administration Information” section of this SPD.

THE HEALTH SAVINGS ACCOUNT

If you elect the $3,200 HDHP with Health Saving Account (HSA) option, you pay for the cost of your care
directly until you reach your annual deductible. After you reach the annual deductible, the Plan pays a
percentage of your cost. Under the HDHP, certain preventive prescription drugs are covered at 100%, without
a deductible. See “Medical at a Glance” on page 17 for applicable coinsurance amounts.
When you enroll in the HDHP, you may be eligible to open an HSA. Once you complete your HSA enrollment,
UHS will make a direct contribution to your HSA of up to $500/employee only coverage and up to $1,000/all
other coverage levels per year. UHS will deposit the employer contribution per pay period. If you elect to
enroll in the HDHP as a new hire, UHS’ annual contribution to your account will be prorated based on your
date of hire. You can also make pre-tax contributions, up to the IRS maximum.

PARTICIPATING IN THE HSA

You are eligible to establish and contribute to the HSA if you are enrolled in the HDHP option, and:
 you are not covered by other health insurance that is not an HSA qualifying plan (this rule does not apply
to specific injury insurance and accident, disability, dental care, vision care, or long-term care)
 you are not claimed as a dependent on someone else’s tax return,
 you are not currently enrolled in Medicare,
 you or your spouse are not enrolled in a Health Reimbursement Arrangement (HRA) or Health Care
Flexible Spending Account (FSA) (unless it is a Limited Purpose FSA),
 you are not receiving benefits from the Veterans Administration or one of their facilities and have a
service-connected disability or have not received any health benefits from the Veterans Administration or
one of their facilities, including prescription drugs within the three months prior to your enrollment in the
HSA.

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 Medical

Please Note: It’s up to you to make sure that you meet the tax requirements to establish and contribute to the
HSA. Neither UHS nor the HSA Administrator has the information or the responsibility to monitor your status.
You should consult with a tax professional for information about your personal tax situation.
Health Savings Accounts are not ERISA benefits offered under the Plan. UHS permits employees to voluntarily
make pre-tax contributions into an individual HSA account.

HOW THE HSA WORKS

The HSA is a tax-advantaged account available to employees who elect the $3,200 High Deductible Health Plan
(HDHP). You contribute to your account through payroll deductions on a pre-tax basis.
The HSA allows you to put aside money before taxes are withheld so that you can pay for current and future
out-of-pocket healthcare costs incurred by you and/or your eligible dependents, including long-term care,
COBRA and Medicare premiums. Your account can also pay for non-qualified medical expenses, although
reimbursement for such expenses are subject to federal, state, and local taxes, as applicable, and in most
cases a penalty tax.
Any unused balance in your account at year-end is carried forward to the next calendar year, even if you do
not participate in the HDHP option next year.
Below are some additional features of the HSA:
 Amounts contributed to the HSA belong to you and are completely portable. If you leave UHS, your HSA
account goes with you. Although you cannot roll the HSA funds over into an IRA, you can roll the HSA
funds into another HSA.
 Every year the money not spent would stay in the HSA and earn interest tax-free, just like an IRA.
 If during the year you do not use all of the funds in your HSA, the money remains in your account and rolls
over to the following year to be used for future healthcare expenses (unlike amounts in Flexible Spending
Accounts that are forfeited if not used by the end of the year).
 Funds can be withdrawn from the HSA for either qualified medical or other expenses. If the amount
withdrawn is used for qualified medical expenses, then the withdrawal is tax free. If the amount
withdrawn is used for expenses other than qualified medical expenses, the amount withdrawn will be
taxed and, for individuals who are not disabled or over age 65, subject to a 20% tax penalty.
 Although UHS is providing you with a vehicle to establish an HSA, responsibility for meeting all the tax rules
is yours. For example, to avoid taxation and possible penalties, it’s up to you to make sure that any
withdrawal you take from the HSA is for a qualified medical expense. Neither UHS nor the HSA
Administrator will monitor your distribution requests for tax compliance — it’s up to you to do this and
keep necessary tax records.

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 Medical

CONTRIBUTIONS
You may contribute to your HSA on a pre-tax basis, up to the IRS maximum. You may change your per-
paycheck contribution amount at any time during the year. If you establish an HSA after January 1 or change
your coverage level under the HDHP option because of a qualified status change, your maximum contribution
generally will be prorated based on the number of full months remaining in the calendar year and your level of
coverage under the HDHP option, however special rules allow employees enrolling mid-year to contribute the
maximum annual contribution provided certain requirements are met. You are responsible for ensuring you
stay within IRS contributions limits for the HSA.
You may make contributions to your HSA on an after-tax basis directly to the HSA Administrator as long as you
meet the tax requirements to contribute to an HSA.
Your pre-tax contributions to your HSA must end on the date:
 you no longer meet eligibility requirements
 you are no longer enrolled in a high deductible health plan
 on which you reach the annual cap for HSA contributions
 you terminate employment
 of your death
 the HDHP plan is terminated.

WITHDRAWALS
In general, you may withdraw from your HSA for qualified medical expenses on a tax-free basis for yourself as
the employee covered by a high deductible health plan, your spouse (even if he or she is not covered by a high
deductible health plan), and your qualifying family members (even if not covered by a high deductible health
plan).
Withdrawals for services and items other than qualified medical expenses are subject to federal, state, and
local taxes, as applicable, and an additional 20% penalty unless the withdrawal occurs after you reach age 65,
are disabled or die.
You may pay for HSA-qualified expenses using your HSA debit card, rather than filing a form for
reimbursement. However, if you do not use your debit card to pay for an expense, you may file a form through
the HSA Administrator and be reimbursed up to your account balance at that time. You may also file a claim
with the HSA Administrator to directly pay your provider.
For guidelines on qualified medical expenses under Internal Revenue Code Section 213, see IRS
Publication 502. However, some items listed in this publication are not reimbursable tax-free under the HSA
(e.g., premiums, except for certain premiums at age 65 or older). For HSA specific requirements under IRC
Section 223, see IRS Publication 969. IRS publications are available at www.irs.gov or by calling the IRS at

Effective January 1, 2024 45

 Medical

(800) 829-3676. You may also check with the HSA Administrator if you have questions about reimbursable
expenses.
As an HSA owner, you are responsible for verifying whether funds are appropriately used for qualified medical
expenses and for maintaining appropriate records. You should consult with a tax professional for information
about your personal tax situation.

ACCESSING YOUR HEALTH SAVINGS ACCOUNT

Optum Financial is the HSA Administrator. For instructions on how to enroll in an HSA and how to use and
manage your account contact Optum Financial at (844) 400-5720 or go to
http://www.myoptumfinancial.com/universal-health-services.
The Optum Financial debit card helps make it easier for you to spend the money in your HSA. When you use
the debit card, it uses the money in your account to pay for eligible expenses. You will receive your debit card
in the mail with instructions for activating it. You can use your debit card at qualified merchants where credit
cards are accepted, and where merchants can process HSA cards, including doctor and dental offices, hospitals
and pharmacies. There may be times that you will be asked to provide documentation that your debit card
was used to pay for an eligible item. When this happens, an alert will appear on your account or you will
receive a Request for Documentation Letter.
If you do not use your debit card, you can request reimbursement from your account. Instructions on using
your debit card and requesting reimbursement can be found by logging on to
https://www.myoptumfinancial.com/universal-health-services or calling Optum Financial at (844) 400-5720.

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 Alternative Health Plans
An Alternative Health Plan (AHP), such as a locally specific Health Maintenance
Organization (HMO), Point of Service Plan (POS), or Preferred Provider
Organization (PPO) may be available in your location. Where available, you may
have one or more additional medical options. Contact your Human Resources
Department for a list of the plans that may be available to you.
AHPs are not offered in all areas and eligibility and coverage rules may vary by
state. AHPs offer access to healthcare through a network of physicians and
facilities. In most plans, you must use an AHP provider to receive maximum
benefits, unless you need emergency care.
The information contained in this Summary Plan Description (SPD) is a general description that applies to most
AHPs. If you choose an AHP option, you will receive benefit information from that carrier. These materials will
provide any special instructions or steps you must follow, including information regarding claim forms,
network providers, copays, dollar limits, and plan exclusions. Contact the AHP directly for more information
about benefits under your plan.
The benefit materials from your AHP are only part of your SPD. Other sections of this SPD also apply to AHPs;
for example, COBRA continuation coverage (see the “Eligibility and Enrollment” section on page 2) and the
Employee Privacy Notice (see the “Plan Administration Information” section on page 162).
In most instances, you may obtain, without charge, a listing of network providers by contacting your local AHP
directly or accessing this information via their website. If you are covered by Medicare and also enrolled in an
HMO, you can obtain a copy of your Evidence of Coverage (EOC) or Summary of Benefits Coverage by visiting
the UHS Benefits Portal and Self-Service Center at https://uhsbenefits.ehr.com and/or your carrier’s website.

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 Alternative Health Plans

In this Section
Your ID Card .................................................................................................................................................................................... 48
Your Options ................................................................................................................................................................................... 49
Preferred Provider Organization (PPO)............................................................................................................................................. 49
Health Maintenance Organizations (HMO) ...................................................................................................................................... 49
Point of Service (POS) ....................................................................................................................................................................... 49
About Your Primary Care Physician ................................................................................................................................................. 49
Designation of Primary Care Providers ............................................................................................................................................. 50
Access to Obstetrical or Gynecological Care..................................................................................................................................... 50
What’s Covered ............................................................................................................................................................................... 50
Primary and Preventive Care ............................................................................................................................................................ 50
Specialty and Facility Care ................................................................................................................................................................ 51
Emergency Care ................................................................................................................................................................................ 51
Prescription Drug Coverage .............................................................................................................................................................. 51
Other Covered Services .................................................................................................................................................................... 51
What’s Not Covered ........................................................................................................................................................................ 51
General Plan Provisions ................................................................................................................................................................... 52
Coordination of Benefits ................................................................................................................................................................... 52
Subrogation ...................................................................................................................................................................................... 52
Claims.............................................................................................................................................................................................. 52
Member Services ............................................................................................................................................................................. 53

YOUR ID CARD
In most instances, when you join your local AHP, you will receive a member ID card. If you enroll dependents,
you may receive one or more additional ID cards. If you require more ID cards or if you have questions about
your ID cards, contact your carrier.
Always carry your ID card with you. It identifies you as a Plan participant when you receive services from
participating providers or when you receive emergency services at nonparticipating facilities. When you obtain
a prescription at a participating pharmacy, remember to present your ID card. If your card is lost or stolen,
please notify your local AHP immediately.
Although a specific service may be listed as a covered benefit, it may not be covered unless it is medically
necessary for the prevention, diagnosis, or treatment of your illness or condition.

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 Alternative Health Plans

YOUR OPTIONS
The facility in which you work determines your Medical Plan eligibility; your Human Resources Department
will provide this information. You are eligible for at least one of the options listed below.

PREFERRED PROVIDER ORGANIZATION (PPO)

If you elect coverage through a PPO Option, you can receive care from any licensed physician and do not need
to select a primary care physician nor obtain a referral before visiting a specialist. Generally, you pay less if you
receive care from physicians and specialists participating in the PPO network. Network providers have agreed
to charge fees determined by the PPO, which are typically lower than fees charged by out-of-network
providers.

HEALTH MAINTENANCE ORGANIZATIONS (HMO)

If you elect coverage through an HMO option, you must select a primary care physician (PCP) and receive care
from physicians and specialists who participate in the HMO network. If you receive care from a network
provider, many services are covered in full. There is no coverage for treatment received out of network,
except in the case of an emergency. Some HMOs have coverage for certain prescription drugs, routine eye
exams, and corrective lens reimbursement.

POINT OF SERVICE (POS)

If you elect coverage through a POS option, you must select a primary care physician (PCP) to monitor your
healthcare. This PCP must be chosen from within the healthcare network, and becomes your “point of
service.” The POS network PCP may then make referrals outside the network, but then only limited benefits
may be available from the Plan.

ABOUT YOUR PRIMARY CARE PHYSICIAN

If you are enrolled in a plan that requires you to choose a primary care physician (PCP), each participant in the
local AHP must select a PCP when they enroll. Your PCP serves as your guide to care and it's recommended
that you use a PCP, even if your AHP does not required you to coordinate your care through a PCP. Your PCP
will provide your basic and routine care, and will refer you to specialists and facilities in the network when
medically necessary.
Selecting a PCP is an important decision. Your choice will determine the level of coverage you receive for
medical care. Please refer to the specific benefit materials provided by your AHP for further information.

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 Alternative Health Plans

As a participant in the AHP, you will become a partner with your participating PCP in preventive medicine.
Consult your PCP whenever you have questions about your health. Your PCP will provide your primary care
and, when medically necessary, refer you to other doctors or facilities for treatment. The referral is important
because it is how your PCP arranges for you to receive necessary, appropriate care and follow-up treatment.
Except for PCP, direct access and emergency services, you must have a prior written or electronic referral from
your PCP to receive coverage for all services and any necessary follow-up treatment.
Participating specialists are required to send reports back to your PCP to keep your PCP informed of any
treatment plans ordered by the specialist.

DESIGNATION OF PRIMARY CARE PROVIDERS

If you are enrolled in a medical benefit plan that requires the designation of a primary care provider, you have
the right to designate any primary care provider who participates in the network and who is available to
accept you or your enrolled family members. Until you make this designation, one may be designated for you.
For information on how to select a primary care provider, and for a list of the participating primary care
providers, contact your health plan.
For children, you may designate a pediatrician as the primary care provider.

ACCESS TO OBSTETRICAL OR GYNECOLOGICAL CARE

You do not need prior authorization from your carrier or from any other person (including a primary care
provider) in order to obtain access to obstetrical or gynecological care from a health care professional who
specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with
certain procedures, including obtaining prior authorization for certain services, following a pre-approved
treatment plan, or procedures for making referrals. For a list of participating health care professionals who
specialize in obstetrics or gynecology, contact your carrier’s Member Services department.

WHAT’S COVERED
The AHP plans pay benefits for the following services.

PRIMARY AND PREVENTIVE CARE

Your PCP can provide preventive care and treat you for illnesses and injuries. The plan may cover routine
physical exams, well-baby care, immunizations, and allergy shots provided by your PCP. In some AHP plans,
you may obtain routine vision exams and gynecological exams from participating providers without a referral
from your PCP. Most plans will cover your preventive care expenses at 100% with no deductible or
copayment. Check for any copayment that may apply as shown in the “Copayment Schedule” in your AHPs
benefit materials.

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 Alternative Health Plans

In general, an AHP’s goal is to help you maintain good health through preventive care. Routine exams,
immunizations, and well-child care contribute to good health and are usually covered by the plan (after any
applicable copayment) if provided by your PCP or on referral from your PCP. You should refer to the benefit
materials of your local AHP for a full listing of covered primary and preventive care benefits.

SPECIALTY AND FACILITY CARE

Your PCP may refer you to a specialist within the service area or a facility for treatment or for covered
preventive care services, when medically necessary. Normally, for direct access benefits and emergency care,
you must have a prior written or electronic referral from your PCP in order to receive coverage for any services
the specialist or facility provides.
When your PCP refers you to a participating specialist or facility for covered services, you will be responsible
for the copayment shown in the “Copayment Schedule.” Refer to the materials provided by your AHP.

EMERGENCY CARE
If you need emergency care, in most cases you are covered 24 hours a day, seven days a week. However, you
must refer to the benefit materials provided by your local AHP to determine access to and payment of benefits
in a medical emergency.

PRESCRIPTION DRUG COVERAGE

When you enroll in an AHP, your prescription drug benefit is provided as part of the AHP. Refer to your AHP
plan specific materials for a description of your prescription drug benefit. The CVS Caremark prescription drug
component of the Medical Plan described elsewhere in the SPD is not part of the AHP benefits.

OTHER COVERED SERVICES

Other covered services under the plan, include:
 specialty and outpatient care
 inpatient care in a hospital, skilled nursing facility or hospice
 behavior healthcare.
Refer to the benefit materials from your local AHP for a full listing and disclosure of these benefits.

WHAT’S NOT COVERED

Refer to the exclusions and limitations in the benefit materials provided by your local AHP.

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 Alternative Health Plans

GENERAL PLAN PROVISIONS

The following describes general provisions of the plan. For specific information about plan provisions for your
plan, review the AHP’s certificates.

COORDINATION OF BENEFITS
If you have coverage under other group plans, the benefits from the other plans may be taken into account if
you have a claim. This may mean a reduction in benefits under the AHP plan. To find out if benefits under the
plan will be reduced, contact your local AHP carrier or refer to the specific benefit materials provided by the
carrier to determine how coordination of benefits will work.

SUBROGATION
If you or a covered family member receives benefits from this plan as the result of an illness or injury caused
by another person, the AHP may seek reimbursement for those benefits from any settlement or payment you
receive from the person who caused the illness or injury.
You must contact your local AHP directly or refer to the specific benefits materials provided by the AHP to
learn the important information about the right of subrogation.

CLAIMS
A claim occurs whenever a plan participant requests:
 an authorization or referral from a participating provider; or
 payment for items or services received.
The AHP has procedures for you to follow if you are dissatisfied with a decision that has been made or with
the operation of the plan. The process depends on the type of complaint you have and the specific
requirements of the local AHP. You must refer to the benefit materials provided by the AHP or contact them
directly. For more information, see “Health Claim Filing and Appeal Procedures” on page 169 in the “Plan
Administration Information” section of this SPD.

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 Alternative Health Plans

MEMBER SERVICES
Your AHP's Member Services phone number is located on your ID card. Contact your AHP’s Member Services
to:
 ask questions about benefits and coverage; or
 change your PCP.
Contact Member services to give notification of any emergency and contact your PCP’s office to ask questions
about appointments, hours of service, or medical matters.

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 Supplemental Insurance Benefits
UHS offers two Supplemental Insurance Benefit options: Accident Insurance and
Critical Illness Insurance. The plans are voluntary benefits through Voya. They add
a layer of financial protection by paying cash directly to you to help cover out-of-
pocket medical or everyday expenses if you are injured in an accident or become
ill. Additional benefits, such as Voya’s Wellness Benefit, are available when you
enroll in one or both of the Supplemental Insurance Benefit options.
Supplemental Insurance Benefits are not an employee benefit plan within the
meaning of ERISA and are not subject to ERISA, HIPAA or COBRA. They are also not
health insurance. They provide limited benefits and are not a substitute for
comprehensive medical coverage, such as the UHS healthcare plan. Lack of
comprehensive medical coverage (or other minimum essential coverage) may
result in an additional payment with your state taxes. Benefit payments are not
intended to cover the full cost of medical care. The payments are in addition to
any other health coverage you may have. Supplemental Insurance Benefits do not
count as minimum essential coverage under the Affordable Care Act.

In this Section
Eligibility.......................................................................................................................................................................................... 55
Eligible Dependents .......................................................................................................................................................................... 55
Enrollment ...................................................................................................................................................................................... 55
Plan Features................................................................................................................................................................................... 56
Cost of Coverage ............................................................................................................................................................................. 56
Accident Insurance .......................................................................................................................................................................... 56
Additional Benefits ........................................................................................................................................................................... 56
What’s Covered ................................................................................................................................................................................ 57
What’s Not Covered.......................................................................................................................................................................... 60
Critical Illness Insurance .................................................................................................................................................................. 61
What’s Covered ................................................................................................................................................................................ 61
Benefit Maximums ............................................................................................................................................................................ 62
Wellness Benefit ............................................................................................................................................................................. 63
How the Plan Pays Benefits .............................................................................................................................................................. 63
Eligible Health Screening Tests ......................................................................................................................................................... 63

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 Supplemental Insurance Benefits

Claims.............................................................................................................................................................................................. 64
Filing a Claim ..................................................................................................................................................................................... 64
If a Claim Is Denied ........................................................................................................................................................................... 64

ELIGIBILITY
You are eligible to enroll 30 days following the date you begin employment or change to a benefit eligible
status, provided you are regularly scheduled to work a minimum of 30 hours per week and you are not
covered by a collective bargaining agreement, unless the agreement provides for such coverage. Eligibility for
employees scheduled to work less than 30 hours per week may vary by UHS location.
Check with your Human Resources Department to confirm your eligibility. You must enroll to be covered by
any benefit plan.

ELIGIBLE DEPENDENTS
Coverage for your eligible dependents is available only if you elect coverage for yourself. Eligible dependents
are:
 your lawful spouse in accordance with federal law and regulations and as long as your spouse does not
also have coverage as a UHS employee
 your children from live birth to age 19 (or to age 23 for full-time students). Your eligible children are:
 your biological children
 your stepchildren
 your legally adopted children, after they have been placed with you and you have assumed legal
obligation for support in anticipation of legal adoption
 children for whom a court order has appointed you or your legal spouse as legal guardian
Call Voya Employee Benefits Customer Benefits Service at (877) 236-7564 or visit
https://presents.voya.com/EBRC/UHS for more information.

ENROLLMENT
You are eligible to enroll during the annual enrollment period each year. If you are a new employee you will
have 30 calendar days to enroll. If you are a newly eligible employee, you may enroll for coverage 30 calendar
days after your status change.
For both Accident Insurance and Critical Illness Insurance, coverage becomes effective following the election
of coverage, on the 31st day as a new hire or newly eligible employee or on the date you elect coverage due to
a qualifying event.

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 Supplemental Insurance Benefits

PLAN FEATURES
Accident Insurance and Critical Illness Insurance include the following features:
 guaranteed issue: No medical questions or tests are required for coverage
 flexibility: You can use the benefit payments for any purpose you like
 portability: If you leave UHS or retire, you can take your coverage with you.

COST OF COVERAGE
You pay for the coverage you elect on a post-tax basis through payroll deductions. The cost of coverage is
based upon the level of coverage you elect, whether you cover dependents and, in the case of Critical Illness
Insurance, your age. For more information, refer to the "2024 UHS All BENEFITS - All Locations - Cost Sheet"
available in your enrollment materials or by contacting your Human Resources Department.

ACCIDENT INSURANCE
Accident Insurance pays cash benefits when you have expenses related to an injury caused by a covered
accident. Two levels of coverage are available: Low Plan or High Plan. See “What’s Covered” on page 57 for
more information about the benefits available under each plan option.
You can use the money any way you wish. For example, you can use the money for:
 medical expenses, such as deductibles, coinsurance and copays
 home health costs, such as rehabilitation and medical equipment
 lost income due to lost time at work
 everyday expenses like utilities and groceries.

ADDITIONAL BENEFITS
When you enroll in Accident Insurance, you receive the following additional benefits:
 Sports Accident Benefit: If your accident occurs while you are participating in an organized sporting
activity, the hospital care, accident care or common injuries benefit, shown in the “What’s Covered” table
on page 57, will be increased by 25%, to a maximum additional benefit of $1,000.
 Voya Travel Assistance: If you are traveling more than 100 miles from home, Voya Travel Assistance,
offered through International Medical Group, provides enhanced security for business or leisure trips. You
and your dependents can take advantage of four types of services: pre-trip information, emergency
personal services, medical assistance services and emergency transportation services. Call Voya at Voya
Employee Benefits Customer Service at (877) 236-7564 or visit https://presents.voya.com/EBRC/UHS for
more information.

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 Supplemental Insurance Benefits

There is no additional cost for the Sports Accident Benefit and the monthly Accident Insurance premium
includes Voya Travel Assistance. You are also eligible for the Wellness benefit. See “Wellness Benefit” on page
63 for information.

WHAT’S COVERED
The following is a summary of the benefits provided under Accident Insurance. The benefit amount depends
on the type of injury and care received. There may be some state-specific variations in the benefits provided.
Contact your carrier for more information.
Event Low High
Accident Hospital Care
Surgery $800 $1,200
(open abdominal, thoracic)
Surgery $125 $175
(exploratory or without repair)
Blood, plasma, platelets $400 $600
Hospital admission $1,000 $1,250
Hospital confinement $225 $275
(per day, up to 365 days)
Critical care unit confinement $350 $600
(per day, up to 15 days)
Rehabilitation facility confinement $125 $200
(per day, up to 90 days)
Coma $11,500 $17,000
(duration of 14 or more days)
Transportation $500 $750
(per trip, up to three per accident)
Lodging $125 $180
(per day, up to 30 days)
Family care $15 $25
(per child, per day, up to 45 days)
Accident Care
Initial doctor visit $150 $225
Urgent care facility treatment $150 $225
Emergency room treatment $150 $225
Ground ambulance $240 $400
Air ambulance $1,000 $1,500
Follow-up doctor treatment $60 $90
Chiropractic treatment $30 $45
(up to six per accident)
Medical equipment $75 $200

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 Supplemental Insurance Benefits

Event Low High

Physical or occupational therapy $30 $45
(up to six per accident)
Speech therapy $30 $45
(up to six per accident)
Prosthetic device $500 $750
(one)
Prosthetic device $800 $1,200
(two or more)
Major diagnostic exam $125 $275
Outpatient surgery $150 $225
(one per accident)
X-ray $50 $100
Common Injuries
Burns $1,000 $1,250
(second degree, at least 36% of the body)
Burns $4,500 $7,500
(third degree, at least nine but less than 35 square inches of the body)
Burns $10,000 $15,000
(third degree, 35 or more square inches of the body)
Skin grafts 50% of the burn benefit 50% of the burn benefit
Emergency dental work $250 crown $350 crown
$60 extraction $90 extraction
Eye injury $60 $100
(removal of foreign object)
Eye injury $225 $350
(surgery)
Torn knee cartilage $150 $225
(surgery with no repair or if cartilage is shaved)
Torn knee cartilage $500 $800
(surgical repair)
Laceration1 $20 $30
(treated no sutures)
Laceration1 $40 $60
(sutures up to 2”)
Laceration1 $160 $240
(sutures 2” to 6”)
Laceration1 $320 $480
(sutures over 6”)
Ruptured disk $500 $800
(surgical repair)

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 Supplemental Insurance Benefits

Event Low High

Tendon/ligament/rotator cuff $275 $425
(exploratory arthroscopic surgery with no repair)
Tendon/ligament/rotator cuff $550 $825
(one, surgical repair)
Tendon/ligament/rotator cuff $800 $1,225
(two or more, surgical repair)
Concussion $150 $225
Paralysis – paraplegia $10,750 $16,000
Paralysis – quadriplegia $16,000 $24,000
Dislocations Closed/open Closed/open
reduction2 reduction2
Hip joint $3,200/$6,400 $4,000/$8,000
Knee $2,000/$4,000 $2,500/$5,000
Ankle or foot bone(s) $1,200/$2,400 $1,700/$3,400
(other than toes)
Shoulder $1,500/$3,000 $2,000/$4,000
Elbow $900/$1,800 $1,250/$2,500
Wrist $900/$1,800 $1,250/$2,500
Finger/toe $250/$500 $300/$600
Hand bone(s) $900/$1,800 $1,250/$2,500
(other than fingers)
Lower jaw $900/$1,800 $1,250/$2,500
Collarbone $900/$1,800 $1,250/$2,500
Partial dislocations 25% of the closed 25% of the closed
reduction amount reduction amount
Fractures Closed/open Closed/open
reduction3 reduction3
Hip $2,500/$5,000 $5,000/$10,000
Leg $1,800/$3,600 $2,700/$5,400
Ankle $1,500/$3,000 $2,250/$4,500
Kneecap $1,500/$3,000 $2,250/$4,500
Foot $1,500/$3,000 $2,250/$4,500
(excluding toes and heel)
Upper arm $1,750/$3,500 $2,400/$4,800
Forearm, hand, wrist $1,500/$3,000 $2,250/$4,500
(except fingers)
Finger, toe $200/$400 $300/$600
Vertebral body $2,800/$5,600 $4,000/$8,000
Vertebral processes $1,200/$2,400 $1,750/$3,500
Pelvis $2,750/$5,500 $3,500/$7,000
(except coccyx)

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 Supplemental Insurance Benefits

Event Low High

Coccyx $300/$600 $450/$900
Bones of face $1,000/$2,000 $1,300/$2,600
(except nose)
Nose $500/$1,000 $650/$1,300
Upper jaw $1,250/$2,500 $1,600/$3,200
Lower jaw $1,200/$2,400 $1,750/$3,500
Collarbone $1,200/$2,400 $1,750/$3,500
Rib or ribs $350/$700 $450/$900
Skull – simple $1,250/$2,500 $1,500/$3,000
(except bones of face)
Skull – depressed $2,500/$5,000 $4,000/$8,000
(except bones of face)
Sternum $300/$600 $400/$800
Shoulder blade $1,500/$3,000 $2,250/$4,500
Chip fractures 25% of the closed 25% of the closed
reduction amount reduction amount
1 Laceration benefits are a total of all lacerations per accident.
2 Closed reduction of dislocation = Non-surgical reduction of a completely separate joint. Open reduction of dislocation = Surgical reduction of a
completely separate joint.
3 Closed reduction of fracture = Non-surgical. Open reduction of fracture = Surgical.

WHAT’S NOT COVERED

Benefits are not payable for any loss caused in whole or directly by any of the following (this list may vary by
state):
 participation or attempt to participate in a felony or illegal activity
 an accident while you are operating a motorized vehicle while intoxicated. Intoxicated means your blood
alcohol content meets or exceeds the legal presumption of intoxication under the laws of the state where
the accident occurred
 suicide, attempted suicide or any intentionally self-inflicted injury, while sane or insane
 war or any act of war, whether declared or undeclared, other than acts of terrorism
 loss sustained while on active duty as a member of the armed forces of any nation. You will be refunded,
upon written notification of your service, for any premium which has been accepted for a period not
covered as a result of this exclusion
 alcoholism, drug abuse or misuse of alcohol or taking of drugs, other than under the direction of a doctor
 riding in or driving any motor-driven vehicle in a race, stunt show or speed test

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 Supplemental Insurance Benefits

 operating, or training to operate, or service as a crew member of, or jumping, parachuting or falling from,
any aircraft or hot air balloon, including those which are not motor-driven. Flying as a fare-paying
passenger is not excluded
 engaging in hang-gliding, bungee jumping, parachuting, sail gliding, parasailing, parakiting, kite surging or
any similar activities
 practicing for, or participating in, any semi-professional or professional competitive athletic contests for
which any type of compensation or renumeration is received
 any sickness or declining process caused by a sickness.

CRITICAL ILLNESS INSURANCE

Critical Illness pays a lump sum benefit if you are diagnosed with a covered illness or condition. When you
enroll in Critical Illness Insurance, you and your covered dependents will also receive coverage under the
Wellness Benefit at no additional cost. See “Wellness Benefit” on page 63 for information.
Two levels of coverage are available:
Plan Critical Illness Benefit Amount
Employee Spouse Children
Low $10,000 $5,000 $5,000
High $20,000 $10,000 $10,000

WHAT’S COVERED
The Critical Illness Benefit Amount is paid for covered illnesses or conditions in the following groups, known as
modules. In some cases, as noted, a percentage of the Critical Illness Benefit Amount will be paid:
Module Covered Illness or Condition
Base  Heart attack1
 Cancer
 Stroke
 Major organ transplant2
 Coronary artery bypass
 Carcinoma in situ (25% of Critical Illness Benefit Amount)
Major organ  Type 1 diabetes
 Severe burns
 Transient ischemic attacks (TIA) (10% of Critical Illness Benefit Amount)
 Ruptured or dissecting aneurysm (10% of Critical Illness Benefit Amount)
 Abnormal aortic aneurysm (10% of Critical Illness Benefit Amount)
 Thoracic aortic aneurysm (10% of Critical Illness Benefit Amount)
 Transcatheter heart valve replacement or repair (10% of Critical Illness Benefit
Amount)
 Coronary angioplasty (10% of Critical Illness Benefit Amount)

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 Supplemental Insurance Benefits

Module Covered Illness or Condition

 Implantable/internal cardioverter defibrillator (ICD) placement (25% of Critical
Illness Benefit Amount)
 Pacemaker placement (10% of Critical Illness Benefit Amount)
 Open heart surgery for valve replacement or repair (25% of Critical Illness Benefit
Amount)
Enhanced cancer  Benign brain tumor
 Skin cancer (10% of Critical Illness Benefit Amount)
 Bone marrow transplant (25% of Critical Illness Benefit Amount)
 Stem cell transplant (25% of Critical Illness Benefit Amount)
Quality of life  Permanent paralysis
 Coma
 Multiple sclerosis
 Amyotrophic lateral sclerosis (ALS)
 Loss of sight, hearing or speech
 Muscular dystrophy
 Occupational HIV or Hepatitis B or C
 Parkinson’s disease
 Advanced dementia, including Alzheimer’s disease
 Infectious disease – hospitalization required3 (25% of Critical Illness Benefit
Amount)
1 A sudden cardiac arrest is not in itself considered a heart attack.
2 Major organ transplant means the irreversible failure of your heart, lung, pancreas, entire kidney or liver, or any combination thereof,
determined by a physician specialized in care of the involved organ.
3 Diagnosis of a severe infectious disease by a doctor, including COVID-19, when the diagnosis occurs on or after the group coverage effective
date AND confinement to a hospital for five or more consecutive days, or in a transitional facility for 14 or more consecutive days. Coverage
for infectious disease effective March 17, 2020.

BENEFIT MAXIMUMS
Each benefit payable will be no more than 100% of the Critical Illness Benefit Amount. You may be eligible to
receive benefit payments for multiple conditions. In this case, each diagnosis must be a different diagnosis. A
different diagnosis is:
 a diagnosis of a covered critical illness that is different from any previously diagnoses illness or condition
 a subsequent diagnosis of a covered critical illness that is for the same illness or condition (including a
cancer that has spread to a different area of the body) as the critical illness for which benefits were
payable under your Critical Illness coverage policy but occurred more than three months after the date of
the previous diagnosis.
In no case will you receive a benefit greater than the maximum amount payable during your (or your
dependent’s) lifetime. The maximum amount payable is five times the Critical Insurance Benefit Amount for
each covered condition. Once the maximum amount payable benefit for a covered condition has been paid,

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 Supplemental Insurance Benefits

no further benefits are payable for that same covered condition. Contact Voya Employee Benefits Customer
Service at (877) 236-7564 or visit https://presents.voya.com/EBRC/UHS for more information.

WELLNESS BENEFIT
If you enroll in Accident Insurance and/or Critical Illness Insurance, you will also receive coverage under the
Wellness Benefit at no cost to you. If you cover your spouse and children under Accident Insurance and Critical
Illness Insurance, they will also receive coverage under the Wellness Benefit at no additional cost.

HOW THE PLAN PAYS BENEFITS

The Wellness Benefit provides an annual cash payment if you complete a health screening test on or after
your coverage effective date. The payment is designed to help offset your costs associated with taking a
health screening test, whether or not there was an out-of-pocket cost to you for taking the test. Use the
benefit in any way you want; there is no requirement for how your benefit can be used.
There is an annual benefit maximum of $75 per year, even if you complete multiple health screening tests
during the year. If you have coverage under both Accident Insurance and Critical Illness Insurance, your annual
benefit maximum is $75 under each. If you cover your spouse and child(ren), a separate benefit maximum
applies for your spouse and for each child:
Accident Insurance Critical Illness Insurance

You (employee) $75 $75

Spouse $75 $75
Child(ren) $75 $75

ELIGIBLE HEALTH SCREENING TESTS

Health screening tests covered under the Wellness Benefit include, but are not limited to, the following:
 Blood test for triglycerides  Chest X-ray  Well child/preventive exams
 Pap smear or thin prep pap test  Mammograph through age 18
 Flexible sigmoidoscopy  Colonoscopy  Biometric screenings
 CEA (blood test for colon  CA 15-3 (breast cancer)  Electrocardiogram (EKG)
cancer)  Stress test on bicycle or  Annual physical exam – adults
 Bone marrow testing treadmill  CA 125 (ovarian cancer)
 Serum cholesterol test for HDL  Fasting blood glucose test  Tests for sexually transmitted
& LDL levels  Thermography infections (STIs)
 Hemoccult stool analysis  PSA (prostate cancer)  Ultrasound screening for
 Serum Protein Electrophoresis abdominal aortic aneurysms
 Hearing test
(myeloma  Hemoglobin A1C (HbA1c)
 Routine eye exam
 Breast ultrasound, sonogram  Bone density screening
 Routine dental exam
MRI

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 Supplemental Insurance Benefits

CLAIMS
Use this information to file claims for benefits under the plan.

FILING A CLAIM
Reliastar (a member of the Voya family of companies) administers claims for Accident Insurance and Critical
Illness Insurance. Call Reliastar’s toll-free number to report your claim: (877) 236-7564.
To file a Wellness Benefit claim, visit Voya.com/claims. Scroll down to the “Have a Wellness Benefit Claim?”
and select “Submit your claim”. Check all products that apply (Accident Insurance and/or Critical Illness
Insurance). Click “Continue” and follow the screen prompts. Once all questions are answered, click “Submit”.
Note:
 The Group Name is: Universal Health Services, Inc
 The Group Number is: 0071157-8.

IF A CLAIM IS DENIED
The supplemental insurance benefits have procedures for you to follow if you are dissatisfied with a decision
that has been made or with the operation of the plan. The process depends on the type of complaint you have
and the specific requirements of the plan. You must refer to the benefit materials provided by the
supplemental insurance benefits or contact Reliastar directly.
For more information, see “Health Claim Filing and Appeal Procedures” on page 169 in the “Plan
Administration Information” section of this SPD.

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 Health Care Flexible
Spending Accounts
A Health Care Flexible Spending Account (Health Care FSA) helps you pay for
eligible medical, prescription drug, dental and vision care expenses that are not
covered under the UHS healthcare program, such as your deductible and
coinsurance. You can open a Health Care FSA to pay for these expenses in a tax-
efficient way.
If you are enrolled in the UHS High Deductible Health Plan or another high
deductible health care plan, IRS regulations do not permit you to participate in the
Health Care FSA.
The Health Care FSA is administered by Optum Financial. Visit the UHS Benefits
Portal and Self-Service Center at https://uhsbenefits.ehr.com or
https://www.myoptumfinancial.com/universal-health-services for more
information.

In this Section
Health Care FSA at a Glance ............................................................................................................................................................ 66
How You Save.................................................................................................................................................................................. 66
Tax-Free Reimbursement ................................................................................................................................................................. 66
Enrollment ...................................................................................................................................................................................... 66
Mid-year Enrollment ......................................................................................................................................................................... 67
Funding Your Account ..................................................................................................................................................................... 67
Use It or Lose It ................................................................................................................................................................................. 67
Military Exception: Access to Unused Funds .................................................................................................................................... 68
Whose Expenses Are Eligible? ......................................................................................................................................................... 68
Eligible Healthcare Expenses ........................................................................................................................................................... 68
Ineligible Expenses .......................................................................................................................................................................... 70
Accessing Your Account ................................................................................................................................................................... 70
Using Your Debit Card ....................................................................................................................................................................... 71
Claims Reimbursement ..................................................................................................................................................................... 71
Claims Deadline ................................................................................................................................................................................ 71
Managing Your Account.................................................................................................................................................................... 71
If You Take a Leave of Absence........................................................................................................................................................ 71
When Your Employment Ends ......................................................................................................................................................... 72

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 Health Care Flexible Spending Accounts

HEALTH CARE FSA AT A GLANCE

Why Participate? To save on taxes by paying for eligible expenses with pre-tax dollars
What’s Reimbursed? Out-of-pocket health care expenses not reimbursed by your health care plans and considered
deductible by the IRS. For example:
 medical and dental plan deductibles, co-insurance and copayments,
 prescription eyeglasses and hearing aids, and/or
 orthodontic expenses
Minimum Contribution $60
Maximum Contribution $3,050
Use It or Lose It Rule For accounts with a balance of $25 or more, up to $610 in unused contributions will
automatically be carried over to the next calendar year and can be applied to eligible expenses
in that year.
Deadline to Submit Claims June 15 of the next year

HOW YOU SAVE

The Health Care FSA allow you to pay for eligible healthcare expenses with pre-tax dollars. With the Health
Care FSA, you set aside pre-tax dollars from your pay through payroll deductions to use toward eligible
expenses. Because your contributions are deducted from your pay before federal income taxes and Social
Security taxes are withheld, you will lower your taxable income and you will benefit from tax savings. You
should check with your tax preparer to determine whether the amounts you set aside are exempt from state
and local taxes.
When you have eligible health care expenses, you may pay using your Optum Financial debit card or you may
submit a claim after service.

TAX-FREE REIMBURSEMENT
For claims reimbursements paid to you, once your claim is approved, you may have a check mailed to you or
you may elect direct deposit of your Health Care FSA reimbursements into your checking or savings account.
These reimbursements are tax-free to you.

ENROLLMENT
You can enroll in the Health Care FSA when you are first eligible or during annual enrollment held each fall.

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 Health Care Flexible Spending Accounts

MID-YEAR ENROLLMENT
You may not enroll or change your Health Care FSA election once you have enrolled for the Plan Year, except if
you experience a qualified life event. No retroactive contributions are permitted. See “Qualified Life Events”
on page 5 in the “Eligibility and Enrollment” section of this SPD for more information.

FUNDING YOUR ACCOUNT

You can contribute up to $3,050 per year on a pre-tax basis to your Health Care FSA to pay for eligible
healthcare expenses. The minimum deposit you can make is $5 a month ($60/year). The maximum may be
adjusted from time to time in accordance with the maximum permitted under IRS regulations.

USE IT OR LOSE IT
If you have a minimum of $25 unused funds in your Health Care FSA at the end of the Plan Year, up to $610
will rollover into the following Plan Year Health Care FSA. You do not have to be actively contributing to the
current Plan Year FSA for the unused funds to rollover. If you are actively contributing to a Health Care FSA,
the rollover amount will be added to your account (even if you are already contributing up to the IRS
maximum). Participants who terminate employment or otherwise lose eligibility to participate in the Health
Care FSA prior to the claim run-out date, which is the last day participants can submit claims for the prior Plan
Year, are not eligible to rollover unused funds unless they have elected COBRA for the Health Care FSA.
You must submit all claims for reimbursement by the deadline. After that, any money remaining in your Health
Care FSA will be forfeited (except for amounts that may be carried over) and used by the plan to defray plan
expenses.
The rollover amount is determined after all expenses for that Plan Year have been reimbursed for that Plan
Year and the claim run out period ends, which is June 15th of each year. The carryover amount may be used to
pay for medical expenses incurred during the entire Plan Year to which it is carried over. Any unused funds in
excess of $610 are forfeited.
Limited Purpose FSA
If you subsequently become enrolled in a High Deductible health care plan and have remaining funds in your
Health Care FSA, a Limited Purpose FSA account will be established for you. This is also known as a “Limited
Use” FSA account. You may use your Limited Purpose FSA to pay for dental, vision and preventive care
expenses only. If you meet the deductible of your High Deductible plan, you may then use your funds for
medical expenses for the remainder of that year. Your Limited Purpose FSA is funded each year, on or about
June 16, with funds of up to $610 that remain in your Health Care FSA from the previous calendar year.
You cannot elect to enroll in the Limited Purpose FSA.

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 Health Care Flexible Spending Accounts

MILITARY EXCEPTION: ACCESS TO UNUSED FUNDS

You may withdraw unused balances in your Health Care FSA if you are a reservist called to active duty for a
period of 180 days or more, or for an indefinite period. You have until June 15th of each year to file a claim for
funds from your prior calendar year FSA. You may request a claim up to the amount you contributed in the
calendar year, as of the date of distribution, minus reimbursements received to date. The distribution need
not be for medical expenses and is subject to all applicable income taxes. For information on how to file a
claim, contact Optum Financial at (844) 400-5720.

WHOSE EXPENSES ARE ELIGIBLE?

You may use your Health Care FSA or Limited Purpose FSA to pay for eligible expenses of:
 Your lawful spouse, in accordance with federal law and regulations.
 Your spouse, which means a person recognized as married to you by the state, possession or territory of
the United States in which you were married, regardless of where you live.
 If you were married in a foreign jurisdiction, your spouse means a person recognized as your spouse
under the laws of at least one state, possession or territory of the United States, regardless of where
you live.
 Your children until the end of the year in which they turn age 26, regardless of student status, whether
they are married or live with you and regardless of whether you provide any support;
 Your mentally or physically disabled adult dependent children who live with you and who are primarily
dependent on you for support.
 Any other person (including a domestic partner) who meets the IRS definition of a tax dependent (without
regard to the income limit) which means an individual whose primary residence is your home, who is a
member of your household, for whom you provide more than one-half of their support, and who is not the
qualifying child (as defined under the Internal Revenue Code) of the employee or any other individual.
(Note, you can treat another person’s qualifying child as a qualifying relative if the child satisfies the other
requirements listed here and if the other person isn’t required to file a tax return and either doesn’t file a
return or files one only to get a refund of withheld income taxes. For example, this could allow tax-free
health coverage for the children of an employee’s non-working domestic partner.)
Please refer to your tax advisor to determine eligible dependents. Under federal tax law, a Health Care FSA
may not be used for expenses of domestic partners or their children, unless they qualify as your eligible
dependent under the specific federal tax law definitions that apply to Health Care FSAs.

ELIGIBLE HEALTHCARE EXPENSES

Only “qualifying” expenses can be reimbursed through the Health Care FSA. Expenses must be incurred during
the Plan Year and while you were covered under the Plan. An expense is considered incurred when the care or
service is provided – not when your provider issues a bill nor when you receive or pay the bill. You may submit

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 Health Care Flexible Spending Accounts

bills for expenses for medical care, as defined in Section 213 of the Internal Revenue Code (except long-term
care premiums and expenses associated with long-term care and other health care premiums) which you are
obligated to pay and which are not covered by any plan.
Expenses eligible to be reimbursed from the Health Care FSA include expenses for the diagnosis, cure,
treatment or prevention of disease, and for treatments affecting any part or function of the body. Expenses
must be to alleviate or prevent a physical or mental defect or illness. Expenses incurred solely for cosmetic
reasons or expenses that are merely beneficial to a person’s general health (except menstrual care products,
smoking cessation and physician-directed weight reduction programs) are not eligible for reimbursement.
These include expenses incurred by you, your spouse and your children through the end of the calendar year
in which the child turns age 26, for the following:
 medicines or prescription drugs, including certain over-the-counter drugs
 insulin
 equipment such as crutches, supplies such as bandages, and diagnostic devices such as blood sugar test
kits, if they are for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose
of affecting any structure or function of the body (expenses for items that are merely beneficial to your
general health are not “qualifying” expenses)
 feminine care products
 sunscreens with SPF ratings of 15 and above
 vaporizers and inhalers
 certain other medical expenses not covered by your medical insurance
 smoking cessation programs and related medicines
 hearing exams, aids and batteries
 certain other medical expenses not covered by your medical insurance
 deductibles, copayment and coinsurance you have paid under any type of healthcare plan.
Here is a partial list of the dental and vision expenses that are eligible for reimbursement, to the extent they
are otherwise covered by your medical, dental and/or vision plan but are out-of-pocket costs:
 vision care expenses:
 eyeglasses
 prescription sunglasses
 contact lenses and supplies
 ophthalmologist fees
 the cost of a guide dog for the blind and special education devices for the blind (such as an interpreter)
 laser surgery
 deductibles, copayment and coinsurance you have paid under any type of vision plan.

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 Health Care Flexible Spending Accounts

 dental care expenses:

 exam and cleaning
 anesthesia
 x-rays
 dentures or other dental appliances
 medically necessary orthodontia expenses for adults or dependents
 charges in excess of Usual and Prevailing Fee Limits
 deductibles, copayment and coinsurance you have paid under any type of dental plan.

INELIGIBLE EXPENSES
Below is a partial list of expenses not eligible for reimbursement under the Health Care FSA. For a complete
list of ineligible expenses, visit https://www.myoptumfinancial.com/universal-health-services or refer to IRS
Publication 502: Medical and Dental Expenses at www.irs.gov.
 premiums, including those paid:
 by you, your spouse or other dependents for coverage under any health plan
 for Medicare
 for long-term care insurance
 for policies that provide coverage for loss of earnings, accidental death, loss of limbs, loss of sight, etc.
 cosmetic procedures such as electrolysis, teeth bleaching, hair transplants or plastic surgery
 expenses that are not primarily for the prevention or alleviation of a physical or mental illness or defect
 long-term care expenses.
The IRS does not allow you to deduct the same expenses on your income tax return for which you are
reimbursed under the Health Care FSA.
You may not use money in your Health Care FSA to pay dependent day care expenses and vice versa. You may
not transfer money between the two accounts.

ACCESSING YOUR ACCOUNT

You can access the funds in your Health Care FSA or Limited Purpose FSA in two ways: use your Optum
Financial debit card or submit a claim for reimbursement.

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 Health Care Flexible Spending Accounts

USING YOUR DEBIT CARD

After you enroll in your Health Care FSA, you will receive an Optum Financial debit card in the mail. Use it like
a credit card to pay for eligible healthcare expenses and the amount will be automatically deducted from your
Health Care FSA or Limited Purpose FSA account without your having to submit a claim. You may not use your
card for your Dependent Day Care FSA account, if enrolled. Optum Financial may request documentation to
verify your expense and to comply with IRS regulations. If you don’t provide documentation when requested,
your card may be deactivated.

CLAIMS REIMBURSEMENT
To claim reimbursement directly from your account without using your debit card, submit your expenses
online at https://www.myoptumfinancial.com/universal-health-services. Your reimbursement will be
deducted from your Health Care FSA or Limited Purpose FSA and will be provided by check or direct deposit
into your checking or savings account. Reimbursement can be made to you or, if you process your claim online
as a “Pay Provider” transaction, the reimbursement can be mailed to your provider. Keep in mind that the
feature to pay the provider directly is available only when using the online claims feature.
Please refer to Optum Financial for a list of acceptable documentation. Note that a cancelled check is not
acceptable documentation.
You may submit your expenses at any time up to the claim filing deadline.
For healthcare expenses, you are eligible for reimbursement up to the total amount you have elected to
deposit for the Plan Year, subject to the plan provisions.

CLAIMS DEADLINE
The deadline to submit claims for reimbursement is June 15th of each year. After that, the prior Plan Year will
be closed for reimbursement and any money remaining in your account will be forfeited, except for any
permitted rollover funds.

MANAGING YOUR ACCOUNT

You can view your Flexible Spending Account balances online at any time at
https://www.myoptumfinancial.com/universal-health-services. To obtain information via the automated
response system at any time, call (844) 400-5720. Customer service representatives are available 24/7.

IF YOU TAKE A LEAVE OF ABSENCE

If you are absent from work and are on a paid leave of absence, your Health Care FSA contributions will
continue to be deducted from your paychecks. You may continue to use the funds in your Health Care or
Limited Purpose FSA for eligible expense items during your leave period. Upon your return from an unpaid

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 Health Care Flexible Spending Accounts

leave of absence your Health Care FSA will automatically recalculate the per pay period contribution amount
based on the number of remaining pay periods in the year in order to make up for missed contributions.
If your status changes to an unpaid leave of absence you will have the opportunity to make changes to your
benefits, including your FSA. If you wish to opt out of the Health Care FSA you must make the change within
30 days from when your status changes. If you elect to discontinue your Health Care FSA, expenses incurred
during the leave are not eligible for reimbursement. You may re-enroll in the benefit when you return from an
unpaid leave of absence or during annual enrollment.

WHEN YOUR EMPLOYMENT ENDS

You may claim reimbursement for eligible healthcare expenses incurred through your last day of coverage
(e.g., your termination date or loss of eligibility). If you terminate employment or otherwise lose eligibility due
to a reduction in scheduled work hours, you may be eligible to continue your Health Care FSA on an after-tax
basis under COBRA through the end of the Plan Year in which you terminate. If you elect to continue your
participation, you must continue to make your contributions, plus pay an additional 2% for administrative
costs. When you first become eligible for benefits, an Initial Notice of COBRA Continuation Rights is mailed to
your home address. When you lose eligibility, you will receive a COBRA notice explaining your continuation
rights. See “COBRA — Your Right to Elect Continuation Benefits” on page 10 in the “Eligibility and Enrollment”
section of this SPD for more information.

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 Dependent Care Flexible
Spending Account
You can pay dependent care expenses through a Dependent Care Flexible
Spending Account (Dependent Care FSA) if you are responsible for the care of an
eligible dependent or dependents, and you must be at work during the time those
dependents are receiving care. If you are married, you will qualify if you and your
spouse both work, or if your spouse is a full-time student or disabled. You can set
aside tax-free money to pay yourself back for dependent day care expenses.
The Dependent Care FSA is not an employee benefit plan within the meaning of
ERISA and is not subject to ERISA, HIPAA or COBRA. The Dependent Care FSA is
administered by Optum Financial. Visit the UHS Benefits Portal and Self-Service
Center at https://uhsbenefits.ehr.com or
https://www.myoptumfinancial.com/universal-health-services for more
information.

In this Section
How You Save.................................................................................................................................................................................. 74
Tax Credit vs. Dependent Care FSA Account .................................................................................................................................... 74
Enrollment ...................................................................................................................................................................................... 74
Mid-year Enrollment ......................................................................................................................................................................... 74
Funding Your Account ..................................................................................................................................................................... 75
Use It or Lose It ................................................................................................................................................................................. 75
Whose Expenses Are Eligible? ......................................................................................................................................................... 75
Eligible Expenses ............................................................................................................................................................................. 76
Ineligible Expenses .......................................................................................................................................................................... 77
Accessing Your Account ................................................................................................................................................................... 77
Claiming Reimbursement ................................................................................................................................................................ 77
Claims Deadline ................................................................................................................................................................................ 78
Managing Your Account.................................................................................................................................................................... 78
If You Take a Leave of Absence........................................................................................................................................................ 78
When Your Employment Ends ......................................................................................................................................................... 79

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 Dependent Care Flexible Spending Account

Why Participate? To save on taxes by paying for eligible expenses with pre-tax dollars
What’s Reimbursed? Eligible expenses to care for your children under age 13 (or a disabled dependent of any
age), so that you (and your spouse if you are married) can work. For example:
 nursery school or day care for children,
 after-school programs for children under age 13, and/or
 day care for a disabled spouse or parent
How Much You Can Contribute Up to $5,000 each year ($2,500 if you are married and you and your spouse file separate
tax returns)
Use It or Lose It Rule Your claims must be incurred in the Plan Year of your election and the first 2½ months of
the following Plan Year (grace period)
All amounts that remain in your Dependent Care FSA as of the June 15 claim deadline are
forfeited — this is the “use or lose it” rule

HOW YOU SAVE

The Dependent Care FSA allows you to pay for eligible child care expenses with pre-tax dollars. You set aside
pre-tax dollars from your pay through payroll deductions to use toward eligible expenses. Because your
contributions are deducted from your pay before federal income taxes and Social Security taxes are withheld,
you will lower your taxable income and benefit from tax savings. You should check with your tax preparer to
determine whether the amounts you set aside are exempt from state and local taxes.
When you have eligible dependent care expenses you must submit a claim after service. A debit card is not
available for Dependent Care expenses.

TAX CREDIT VS. DEPENDENT CARE FSA ACCOUNT

Expenses reimbursed through the Dependent Care FSA are the same kind that are allowed as federal tax
deductions and credits. You can use either a Dependent Care FSA or federal income tax credit to gain tax
advantage. You can use both, but not for the same expense. Consult a tax advisor for the best approach for
you.

ENROLLMENT
You can sign up for the Dependent Care FSA when you are first eligible or during annual enrollment held each
fall.

MID-YEAR ENROLLMENT
You may not enroll or change your Dependent Care FSA election once you have enrolled for the Plan Year,
except if you experience a life event or status change. Retroactive contributions are not permitted. See
“Qualified Life Events” on page 5 in the “Eligibility and Enrollment” section of this SPD for more information.

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 Dependent Care Flexible Spending Account

Mid-year Changes
Other events that may permit a corresponding change in your Dependent Care FSA contributions include:
 changes from one child care provider to another and there is a different rate
 you or your spouse are no longer employed
 a qualifying child reaches age 13 and the care is no longer eligible for reimbursement
 you marry, divorce or separate and the number of eligible children changes.

FUNDING YOUR ACCOUNT

You can deposit up to $5,000 per year on a pre-tax basis, regardless of the actual number of qualifying
dependents you have, or $2,500 per year if you are married but file a separate tax return. If your spouse also
has a Dependent Care FSA, whether through UHS or another employer, and you file a joint tax return, the
$5,000 limit will apply to the aggregate contributions you can make to your accounts. For example, if your
spouse contributes $4,000 to his or her account, you may contribute only $83.33 per month ($1,000 for the
full year) to your account.
In addition, your annual Dependent Care FSA deposit can never be more than your earned wages or your
spouse’s earned wages, whichever is less. Refer to IRS Publication 502 and your tax advisor for further limits
on annual deposits.

USE IT OR LOSE IT
It is important to plan your contributions to the Dependent Care FSA carefully. The IRS requires that you must
use the full amount of money in your Dependent Care FSA account for expenses in the defined claims
accumulation period or forfeit what remains. Your request for reimbursement must be filed by June 15 of the
following Plan Year. Any fund remaining in your account after that date will be forfeited. For more
information, see “Claiming Reimbursement” on page 77.
You may not use the money in your Dependent Care FSA to pay for health care expenses or vice versa.

WHOSE EXPENSES ARE ELIGIBLE?

You may be reimbursed for expenses relating to the care of the following qualifying dependents, as defined in
Internal Revenue Code Section 152. Generally, a qualifying child or relative is:
 your child under age 13 who is your qualifying child (as defined under the Internal Revenue Code);
 your disabled spouse who lives with you for more than one half the year; and
 any other relative or household member who receives more than one-half of his or her support from you,
resides in your home, is physically or mentally unable to care for him or herself, and is not the qualifying
child of the employee or any other individual.

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 Dependent Care Flexible Spending Account

A dependent may not be a person who lives outside of your home; therefore, an individual who lives in a
nursing home is not a qualifying dependent.
If you and your spouse are divorced, refer to IRS Publication 503 for more information on when you may be
able to be reimbursed from the Dependent Care FSA. You should consult your tax advisor to determine
whether an individual qualifies as your dependent.
If two married or related UHS employees both maintain Dependent Care FSAs, an expense incurred on behalf
of their dependent may be submitted only to one spending account for reimbursement. Double
reimbursement is not permitted.

ELIGIBLE EXPENSES
The following list of expenses may be reimbursed so that you, the employee (and your spouse, if you are
married), can work or look for work. Expenses may also be reimbursed so that your spouse can attend school
full-time or if your spouse is physically or mentally unable to care for himself or herself. To be eligible,
expenses must have been incurred during the Plan Year and while you were covered under the Plan. An
expense is considered incurred when the care or service is provided—not when your provider issues a bill, nor
when you receive or pay that bill. Eligible expenses include, but are not limited to:
 qualified child or adult day care center expenses, provided the center meets state or local regulations,
provides care for more than six non-resident persons, and receives a fee for such services, whether or not
for profit
 before-school care, after-school care, or extended day programs (supervised activities for children after
the regular school program) if used to enable the employee and spouse to work
 a babysitter or companion inside or outside the home
 a housekeeper, nanny, or au pair to the extent the expenses are for the care of a qualifying individual
 a relative (who is not your dependent nor a child under age 19) who cares for a dependent
 someone who cares for an elderly or disabled dependent in your home
 nursery school or pre-kindergarten expenses at a state-licensed facility
 kindergarten expenses (not including private kindergarten), but only the portion for before-school or after-
school care rather than tuition for education
 agency, application, deposit, or other registration fees if necessary to obtain the related care
 custodial expenses not attributable to medical services and if primary purpose for care is safety and well-
being, provided the qualifying individual spends at least eight hours each day in the employee’s household
 summer day camp tuition (including specialty camp) or a similar program to care for a qualifying individual
(separate equipment or similar charges do not qualify)
 FICA and FUTA taxes of day care provider, as long as the overall expenses of the care provider qualify

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 Dependent Care Flexible Spending Account

 late fees charged to care for the child because the child was not picked up on time if the fee directly
relates to care
 sick-child facility expenses (care to enable the employee to go to work when the child is ill)
 transportation costs to and from the location where the care or program is provided if the transportation
is provided by the day care provider, or if the expense is inseparable from the cost of care.

INELIGIBLE EXPENSES
The following are not considered qualifying dependent day care expenses and cannot be reimbursed from the
Dependent Care FSA. There may be other expenses, in addition to those listed below, which are not eligible.
 payments for babysitters when you are not working, such as in the evening or on weekends
 private school tuition, including private kindergarten expenses that are not considered before-school or
after-school care
 educational expenses for children in kindergarten or higher
 boarding school tuition
 overnight camp expenses
 24-hour-a-day nursing home expenses
 transportation costs to and from the location where the care or program is provided, unless the expense is
inseparable from the cost of the program or transportation is provided by the day care provider
 expenses for food, clothing, education, or entertainment incurred for the normal care of an eligible
dependent, unless these expenses are incidental and cannot be separated from the cost of care
 cost for care that enables your spouse to do volunteer work
 private kindergarten expenses.
You can obtain a more complete list at www.irs.gov/pub/irs-pdf/p503.pdf.
You may not use money in your Dependent Care FSA to pay health care expenses and vice versa. You may not
transfer money between the two accounts.

ACCESSING YOUR ACCOUNT

You can access the funds in your Dependent Care FSA by submitting a claim for reimbursement.

CLAIMING REIMBURSEMENT
To claim reimbursement directly from your account, submit your dependent day care expenses online at
https://www.myoptumfinancial.com/universal-health-services. Your reimbursement will be deducted from
your Dependent Care FSA account and will be provided by check or direct deposit into your checking or
savings account. Reimbursement can be made to you or, if you process your claim online as a “Pay Them”

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 Dependent Care Flexible Spending Account

transaction, the reimbursement can be mailed to your provider. Keep in mind that the feature to pay the
provider directly is available only when using the online claims feature.
Please refer to Optum Financial for a list of acceptable documentation. Note that a cancelled check is not
acceptable documentation.
You may submit your expenses at any time up to the claim filing deadline.
For dependent care expenses, you will be reimbursed up the amount in your account. If your claim exceeds
your account balance, we will automatically reimburse you for any expense over what you have in your
account as more money is deposited.

CLAIMS DEADLINE
The claims accumulation period for the Dependent Care FSAs is 14½ months. This means you can use the
money in your account for eligible expenses you incur during the Plan Year and the first 2½ months of the
following Plan Year (called the “grace period”). You can also submit expenses incurred in the first 45 days of
the prior calendar year to your current year account if your claim balance for the prior Plan Year is exhausted.
Claims incurred during the grace period will be applied to your prior year accounts first. When that money is
exhausted, claims will be applied to your current year accounts.
The deadline to submit claims for reimbursement is June 15th of each year. After that, the prior Plan Year will
be closed for reimbursement and any money remaining in your account will be forfeited.

MANAGING YOUR ACCOUNT

You can view your Flexible Spending Account balances online at any time at
https://www.myoptumfinancial.com/universal-health-services. To obtain information via the automated
response system at any time, call (844) 400-5720. Customer service representatives are available 24/7.

IF YOU TAKE A LEAVE OF ABSENCE

If you are absent from work and are on a paid leave of absence, your Dependent Care FSA contributions will
continue to be deducted from your paychecks. Should your status change to an unpaid leave of absence your
Dependent Care FSA will stop being effective as of the date of the status change. Your original annual
Dependent Care FSA election will be reinstated effective the day you return from your unpaid leave of
absence. The amount will automatically recalculate the per pay period contribution but you will maintain your
original election amount.

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 Dependent Care Flexible Spending Account

You will have a choice to resume contributions at the same level in effect before your leave, or you may elect
to increase your contributions to “make up” for contributions you missed during your leave period. If you
simply resume your prior contribution level, the amount available for reimbursement for the year will be
reduced by the contributions missed during your leave. Regardless of whether you choose to resume your
former contribution level, or make up for missed contributions, expenses incurred while your account
participation is suspended will not be reimbursed.

WHEN YOUR EMPLOYMENT ENDS

The Dependent Care FSA is not eligible for COBRA continuation. However, you may claim reimbursement for
eligible dependent day care expenses incurred through the remainder of the Plan Year in which you terminate
employment or otherwise lose eligibility. Eligible claims will be reimbursed up to the amount you contributed
prior to termination of employment.

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 Dental Plan
The Dental Plan offers two plan options that pay benefits for the same care and
services. They differ in how much you pay each pay period for coverage and how
much you pay at the time you receive services. Both plans use the Delta Dental
PPOSM and Delta Dental Premier® programs to help save you money.
Delta Dental offers two networks:
 the Delta Dental PPOSM network, where you likely pay the lowest amount for services, or
 the Delta Dental Premier® network, where you likely pay a slightly higher amount for services.
The Premier network has a slightly higher number of participating dentists.
Delta Dental PPO and Premier participating dentists agree to accept the applicable Delta Dental negotiated
allowance or the dentist’s actual charge, whichever is less (the allowed amount), as payment in full for
covered services. Both the PPO and Premier networks offer you savings over a non-Delta Dental dentist. For
more information on participating dentists in your area, contact Delta Dental.

In this Section
Dental at a Glance ........................................................................................................................................................................... 81
How the Plan Pays Benefits ............................................................................................................................................................. 81
The Deductible .................................................................................................................................................................................. 81
Maximum Benefit ............................................................................................................................................................................. 82
Covered Charge Requirements ......................................................................................................................................................... 82
Pretreatment Review ........................................................................................................................................................................ 82
What’s Covered ............................................................................................................................................................................... 82
Diagnostic and Preventive Services .................................................................................................................................................. 82
Basic and Major Restorative Services ............................................................................................................................................... 83
Orthodontic Services ........................................................................................................................................................................ 83
Enhanced Pregnancy Benefit ............................................................................................................................................................ 84
What’s Not Covered ........................................................................................................................................................................ 84
Coordination of Benefits ................................................................................................................................................................. 85
Claims.............................................................................................................................................................................................. 85
Filing a Claim ..................................................................................................................................................................................... 85
If a Claim Is Denied ........................................................................................................................................................................... 85

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 Dental Plan

DENTAL AT A GLANCE
The following chart summarizes your benefits:
Features $1,000 Annual Plan Maximum $1,500 Annual Plan Maximum
Preventive Services
Annual Deductible $0 $0
Coinsurance You pay 20% You pay 0%
Plan pays 80% Plan pays 100%
Basic and Major Services
Annual Deductible $50 per person $50 per person
$150 per family $150 per family
Coinsurance You pay 50% You pay 25%
Plan pays 50% Plan pays 75%
Annual Maximum
For Preventive, Basic, and Major Services $1,000 per person $1,500 per person
Combined
Orthodontic Services
Annual Deductible $50 per lifetime $50 per lifetime
Coinsurance You pay 50% You pay 50%
Plan pays 50% Plan pays 50%
Maximum Benefits $1,000 per lifetime $1,500 per lifetime

HOW THE PLAN PAYS BENEFITS

The following describes how the Dental Plan pays benefits.

THE DEDUCTIBLE
The amount that you pay out-of-pocket for covered charges before benefits are payable is called the
deductible. Each person must pay the deductible for covered dental charges each calendar year before
benefits are paid. However, there will be no deductible required for X-rays, two examinations, two cleanings,
and certain other diagnostic and preventive treatments each year for each covered person.
The deductible has some important features that affect the expense you pay out-of-pocket.
 Family Deductible: If any three covered members of a family satisfy the $50 deductible in a calendar year,
the deductible for all other covered members will be satisfied for that year.
 Orthodontic Deductible: A separate orthodontic deductible of $50 must be satisfied each time you or a
dependent begins to receive orthodontic treatment.

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 Dental Plan

MAXIMUM BENEFIT
There is an annual maximum dental benefit for each covered family member. This means that the plan will pay
up to the maximum, either $1,000 or $1,500, for covered charges in any one calendar year for any one person.
There is also an individual lifetime maximum orthodontic benefit. This is a separate maximum and applies to
all orthodontic treatment received by a covered family member.

COVERED CHARGE REQUIREMENTS

Before any of the charges are paid, the following requirements must be met:
 usual, customary, and regular charges, which means the usual charge in your area for comparable dental
care by a person of similar training and experience, will be considered when paying claims
 the service must be essential to the proper care of your teeth
 the service must be performed by or under the direction of a licensed dentist
 the service must be performed while you or your dependent is covered by the plan.

PRETREATMENT REVIEW
A pretreatment review protects you from unexpected dental expenses.
If you or a covered dependent expects to incur dental expenses over $300, your dentist may file for a
pretreatment review. This is not necessary, however, if treatment is of an emergency nature:
 your dentist will complete the pretreatment process with Delta
 Delta will review the treatment plan; and both you and the dentist will receive a notice indicating the
amount eligible for payment.
You and your dentist should discuss the review before the work is performed. When the dentist completes
treatment, he or she should provide the claim information to Delta.

WHAT’S COVERED
The Dental Plan will pay benefit for the following services.

DIAGNOSTIC AND PREVENTIVE SERVICES

The Dental Plan emphasizes diagnostic and preventive care and is designed to encourage you to visit your
dentist regularly. There is no deductible for diagnostic or preventive services, and covered services are paid at
the reasonable and customary rates.

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Diagnostic and preventive care Includes:

 two regular check-ups per calendar year
 one complete series of X-rays within a three-year year period from the last date performed
 two bitewing X-rays per calendar year
 two regular cleanings per calendar year
 space maintainers for covered individuals under 16 once in any five-year period
 fluoride treatments once each calendar year for covered individuals under 19
 sealant applications once per tooth within a three-year period for teeth without cavities for covered
individuals under 19 years of age.
For more information on covered preventive services, contact Delta Dental.

BASIC AND MAJOR RESTORATIVE SERVICES

For Basic and Major Restorative Services, there is a $50 individual deductible and a $150 maximum family
deductible. After the deductible is satisfied, the plan pays benefits at the reasonable and customary rates.
Once the annual individual maximum is paid from the plan, you are responsible for 100% of these services. In
general, these covered services include:
 Restorative Services: fillings, crowns, inlays and treatment necessary to restore the structure of a tooth or
teeth.
 Endodontics: procedures involved in root canal therapy.
 Periodontics: procedures for treatment of the gums and tissues supporting the teeth.
 Prosthodontics: fix bridges and implants, including bridge pontics, abutments, repairs and crowns.
 Oral Surgery: extractions, incision, and other surgical and repair procedures.
 General Anesthesia: covered only when medically necessary and in connection with oral surgery.

ORTHODONTIC SERVICES
In addition to the covered dental expenses listed above, there is special coverage for orthodontic expenses. If
you or a dependent receives orthodontic treatment, you must satisfy the separate $50 orthodontic deductible
per lifetime before the plan pays 50%. The individual maximum benefit per lifetime is listed in the Dental at a
Glance chart.

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ENHANCED PREGNANCY BENEFIT

Enhanced benefits during pregnancy are covered and include an additional oral evaluation and choice of an
additional periodontal scaling/root planing, additional prophylaxis, or additional periodontal maintenance
procedure.

WHAT’S NOT COVERED

The Dental Plan does not pay benefits for:
 charges for services which are not necessary for treatment of dental disease
 expenses which are paid by any other Universal Health Services, Inc. benefit plan
 cosmetic services or supplies
 charges for the replacement of lost, missing, or stolen dentures
 charges for the replacement of dentures, fixed, or removable bridges which are less than five years old and
can be made serviceable
 any claim filed more than one year from the date of service
 charges for missed appointments with your dentist
 charges for completing claim forms
 charges for periodontal splinting (temporary wiring or permanently bonding teeth together)
 charges for appliances, restorations, and procedures to alter vertical dimensions (the proper alignment of
the teeth for chewing or for the treatment of temporal mandibular joint dysfunction)
 charges for drugs and their administration (these are covered under the Medical Plan)
 charges for anesthesia (except general anesthesia, when medically necessary and in connection with oral
surgery)
 hospital charges
 charges for experimental procedures
 charges resulting from an accident to sound natural teeth
 charges for the replacement of any cast restoration (inlay, onlay, crown) for the same or different type of
cast restoration within five years from the prior replacement
 charges that would not have been made if no insurance existed; charges which you are not required to
pay, or which you are entitled to have paid under laws or regulations of any government (including federal,
state, provincial, local or any political subdivision thereof) of the United States or any other country
 charges for treatment in connection with occupational accidents or diseases covered by any workers'
compensation or similar law.

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Some limitations come under an alternative treatment provision. Our plan covers reasonable and customary
expenses — those customarily charged nationwide to treat a condition similar to yours. If there is an
alternative means of treatment, the benefits will usually cover the customary treatment.

COORDINATION OF BENEFITS
When you or your covered dependent(s) are eligible for benefits under another group plan, one of the plans
involved will pay first — the primary plan — and the other plan(s) will pay benefits next — the secondary
plan(s). The primary plan pays benefits first, without considering the other plans. The secondary plan then
makes up the difference, up to the maximum amount of the allowable expenses.
Under this provision, the total benefits paid from all group plans will not exceed the allowable expenses.
Allowable expenses are reasonable and customary charges for dental services or treatment that is covered in
whole or in part by either plan.
If this situation applies to you, be sure to include full details of your other coverage when completing the claim
form.

CLAIMS
Use this information to file claims for benefits under the plan.

FILING A CLAIM
Most dentists file claims for services electronically. If you or your dentist need assistance in filing a claim,
contact Delta Dental. Both you and your dentist will receive notice of how the claim was processed and what,
if any charges, are your responsibility.

IF A CLAIM IS DENIED
If Delta Dental denies your claim, in whole or in part, you or your authorized representative is entitled to have
your claim decision reviewed. Normally, the review will settle a disputed claim. However, if you still feel a
claim is unfairly denied, you have certain rights under federal law.
For additional information, refer to “Health Claim Filing and Appeal Procedures” on page 169 of the “Plan
Administration Information” section of this SPD for more information.

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 Vision Plan
The Vision Plan covers routine eye exams and corrective lenses, frames, and
contacts through Vision Service Plan (VSP), a nationwide network of participating
providers and retail locations. You may also elect to receive care and/or purchase
corrective eyewear at non-participating providers; however, your out-of-pocket
costs may be higher.
For a list of participating providers in your area, or to make certain that your
provider is in the network, call VSP directly at (800) 877-7195 or visit
www.vsp.com.

In this Section
Vision at a Glance ............................................................................................................................................................................ 87
What’s Covered ............................................................................................................................................................................... 87
Routine Eye Exam ............................................................................................................................................................................. 87
Lenses ............................................................................................................................................................................................... 88
Frames .............................................................................................................................................................................................. 88
Contacts Versus Glasses ................................................................................................................................................................... 88
Medically Necessary Contact Lenses ................................................................................................................................................ 88
Low Vision Benefits ........................................................................................................................................................................... 89
What’s Not Covered ........................................................................................................................................................................ 89
Claims.............................................................................................................................................................................................. 89
Filing a Claim ..................................................................................................................................................................................... 89
If a Claim Is Denied ........................................................................................................................................................................... 90

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VISION AT A GLANCE
The following chart summarizes what the plan will pay if you receive services from a VSP Choice network
provider. For detailed benefit coverage information, visit the UHS Benefits Portal and Self-Service Center at
https://uhsbenefits.ehr.com.
Benefits if You Use a Benefit Payable if You Use a
VSP Choice Network Provider Non-VSP Participating Provider
Vision Exam Plan pays 100% after $10 copay Plan pays up to a $40 allowance
(One every calendar year)
Clear Lenses (One pair every calendar year)
Single Vision After $25 copay, plan pays 100% Plan pays up to a $40 allowance
Lined Bifocal After $25 copay, plan pays 100% Plan pays up to a $60 allowance
Lined Trifocal After $25 copay, plan pays 100% Plan pays up to a $80 allowance
Lenticular After $25 copay, plan pays 100% Plan pays up to a $90 allowance
Frames (One every calendar year) OR Contacts (Once every calendar year)
Frames $150 allowance1 plus 20% discount on Plan pays up to a $51 allowance
amounts over the allowance
Contacts Medically necessary2: After $25 copay, plan Medically necessary2: Plan pays up to a $210
(Instead of lenses and frames; pays 100% up to usual and customary charges allowance
includes vision exam) Cosmetic: After $200 allowance3, you pay Cosmetic: Plan pays up to a $200 allowance
100%
1 $80 allowance at Costco, Walmart, and Sam’s Club
2 Contacts necessary to correct an eye disease or deficiency that cannot be corrected by wearing glasses
3 Contact lens exam (fitting and evaluation) charge is not included in the allowance above. Contact lens exam charges may vary by provider; not
to exceed a copay of $60.

WHAT’S COVERED
When you use a VSP Choice Network Provider, the plan pays 100% of the cost for the following services after
you meet any applicable copay.
If you use a non-VSP Choice Network provider, the plan covers these services, but the benefits will be lower
and you will have to file a claim for reimbursement within one year of the service date.

ROUTINE EYE EXAM

Once every calendar year, the plan covers a complete analysis of the eyes and related structures to determine
the presence of vision problems.

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LENSES
Once every calendar year, the plan covers clear lenses. This plan is designed to cover your visual needs rather
than cosmetic materials. There will be extra cost if you select:
 polycarbonate lenses (covered in full for enrolled dependents through age 18)
 seamless multifocal lenses
 cosmetic contact lenses (in excess of the plan allowance)
 tinted or coated lenses
 photochromic lenses
 sun lenses.

FRAMES
The plan covers frames. If you select a frame which costs more than the amount allowed by the plan ($150),
there is an additional charge. The overage amount will be discounted 20%. The allowance is available once
every calendar year.

CONTACTS VERSUS GLASSES

If you select contact lenses instead of glasses, they are considered cosmetic in nature. The plan will provide an
allowance of up to $200 towards the purchase of cosmetic contact lenses. This is instead of all other benefits
for the benefit period.

MEDICALLY NECESSARY CONTACT LENSES

Contact lenses are considered medically necessary under the following circumstances:
 following cataract surgery
 to correct extreme visual acuity problems not correctable with spectacle lenses
 to correct for significant anisometropia
 keratoconus.

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LOW VISION BENEFITS

The plan covers professional services for severe visual problems not correctable with regular lenses, including
supplemental testing and supplemental aids.
 supplemental testing includes evaluation, diagnosis, and prescription of vision aids where indicated, and is
covered in full at a VSP Choice Network Provider and up to $125 at a non-VSP Provider.
 supplemental aids are covered at 75% of the amount, up to a maximum benefit of $1,000, at either a VSP
Choice Network Provider or a non-VSP Provider.
The maximum benefit for all low vision services and materials is $1,000 every two calendar years.
Low vision benefits obtained from non-VSP providers, if covered, are subject to the same frequency and
copayment provisions described above for VSP Choice Network Providers. You should pay the non-VSP
provider’s full fee at the time of service and submit a claim for reimbursement. You will be reimbursed up to
the amount that VSP would pay to a VSP Choice Network Provider for the same services and/or materials.
There is no assurance that the amount reimbursed will cover 75% of the provider’s full fee.

WHAT’S NOT COVERED

There are no benefits for professional services or materials connected with:
 orthoptics or vision training, subnormal vision aids, or non-prescription lenses
 medical or surgical treatment of the eyes
 lenses and frames furnished under this program which are lost or broken. These will not be replaced
unless you are eligible for frames or lenses at that time
 two pairs of glasses instead of bifocals
 services or materials provided as a result of any Workers' Compensation Law or similar legislation
 any eye examination required by an employer as a condition of employment, or any services or materials
provided by any other vision care plan or group benefit plan containing benefits for vision care.

CLAIMS
If you use a non-VSP provider, you must submit your charges to VSP for reimbursement. You do not need to
complete a claim for services received in network.

FILING A CLAIM
Log in to your account on www.vsp.com and select My Benefits to complete the Out-of- Network Claim Form.

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IF A CLAIM IS DENIED
If your claim is denied, in whole or in part, VSP will notify you of the denial in writing. The notice will explain
why benefits were denied. To appeal the denial of benefits, you must write to VSP (to the attention of the
person or department who signed the letter denying benefits) within 180 days of the date of the denial letter.
In your letter, state why you think your claim should not have been denied. Also include any other documents,
data, information, or comments which may have a bearing on your claim.
VSP will review your appeal and will notify you in writing of the decision within 60 days of the date your
appeal is received. In unusual cases, such as those which require review by optometric specialists of technical
records, the review may take longer than 60 days and you will be notified that extra time is needed.

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 Life and Accidental Death &
Dismemberment Plan
The Life and Accidental Death & Dismemberment (AD&D) insurance Plan through
The Hartford Life and Accident Insurance Company provides financial protection
for you and your family in the event of your death or accidental injury. All benefit-
eligible employees will receive basic life insurance coverage equal to one times
annual base pay up to a maximum of $500,000. Both you and UHS contribute to
the cost of your basic life insurance coverage. You may purchase Supplemental Life
and AD&D Insurance for yourself at group rates through payroll deductions.

In this Section
Life and AD&D Insurance at a Glance .............................................................................................................................................. 92
Eligibility.......................................................................................................................................................................................... 92
Cost of Coverage ............................................................................................................................................................................. 93
Imputed Income ............................................................................................................................................................................... 93
How Life Insurance Works ............................................................................................................................................................... 93
Basic Annual Earnings ....................................................................................................................................................................... 93
Proof of Good Health ........................................................................................................................................................................ 93
Accelerated Death Benefit ................................................................................................................................................................ 94
Conversion ........................................................................................................................................................................................ 94
Portability ......................................................................................................................................................................................... 95
How AD&D Insurance Works ........................................................................................................................................................... 95
Actively at Work Provision ................................................................................................................................................................ 95
How AD&D Benefits Are Paid ........................................................................................................................................................... 96
What’s Not Covered.......................................................................................................................................................................... 97
Additional Benefits .......................................................................................................................................................................... 97
Accident Hospital Income Benefit .................................................................................................................................................... 97
Child Education Benefit .................................................................................................................................................................... 98
HIV Occupational Accident Benefit ................................................................................................................................................... 98
Rehabilitation Benefit ....................................................................................................................................................................... 98
Repatriation of Remains Benefits ..................................................................................................................................................... 98
Seat Belt/Air Bag Benefit .................................................................................................................................................................. 98
Spouse Education Benefit ................................................................................................................................................................. 99
General Life and AD&D Information ................................................................................................................................................ 99
Effective Date of Insurance ............................................................................................................................................................... 99
Policy and Certificate ........................................................................................................................................................................ 99
Assignments ...................................................................................................................................................................................... 99

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 Life and Accidental Death & Dismemberment Plan

Designating Beneficiaries .............................................................................................................................................................. 100

Claims............................................................................................................................................................................................ 100
Filing a Claim ................................................................................................................................................................................... 100
If a Claim Is Denied ......................................................................................................................................................................... 100
When Coverage Ends ..................................................................................................................................................................... 101

LIFE AND AD&D INSURANCE AT A GLANCE

The following chart summarizes your benefits under the Plan.
Basic Life1 One times Basic Annual Earnings. Maximum $500,000

Basic AD&D One times Basic Annual Earnings. Maximum $500,000

Supplemental Group Life1 Your options include2:

Optional  one times Basic Annual Earnings
Post-tax benefit  two times Basic Annual Earnings
 three times Basic Annual Earnings
 four times Basic Annual Earnings
 five times Basic Annual Earnings
 six times Basic Annual Earnings
 seven times Basic Annual Earnings

Supplemental Group Life Age Reductions: Group Life and Accidental Death and Dismemberment benefits reduce to:
Insurance and Supplemental  80% for employees age 70 through 74
AD&D Benefit Age
 70% for employees age 75 through 79
Reductions3
 65% for employees age 80 through 84
 60% for employees age 85 or over

1 The maximum benefit for basic life is independent and separate from the maximum benefit for supplemental life.
2 Maximum coverage is $1,000,000.
3 Benefit age reductions are applied at the beginning of each Plan Year if you reach the milestone age in that year. Age reductions also apply to
employees who enroll in the Plan at age 70 or over.

ELIGIBILITY
You are eligible for coverage 30 days following the date you begin employment or change to a benefit-eligible
status, provided you are regularly scheduled to work a minimum of 30 hours per week and you are not
covered by a collective bargaining agreement, unless the agreement provides for such coverage. Eligibility for
employees scheduled to work less than 30 hours per week may vary by UHS location.
Check with your Human Resources Department to confirm your eligibility. You are automatically enrolled in
Basic Life and AD&D insurance; you must enroll in Supplemental Group Life insurance to be covered.

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 Life and Accidental Death & Dismemberment Plan

COST OF COVERAGE
Both you and UHS contribute to the cost of Basic Life and any Supplemental Life Insurance coverage you elect.
Your contributions are made on a post-tax basis through payroll deductions. The cost of coverage is based
upon your age and the level of coverage you elect. Your personal costs are on your enrollment record in the
UHS enrollment system.

IMPUTED INCOME
By law, income taxes apply to the value of your UHS-paid basic life insurance above $50,000. This value is
called “imputed income” and becomes a part of your taxable income reported on your W-2.

HOW LIFE INSURANCE WORKS

BASIC ANNUAL EARNINGS

Your coverage for the calendar year is determined by your Basic Annual Earnings. When you first enroll for
coverage, your Basic Annual Earnings is determined as of your date of hire. Each January 1, your coverage is
adjusted to reflect your Basic Annual Earnings in effect on the previous October 1.
Basic Annual Earnings does not include:
 bonuses,
 settlement pay,
 overtime pay, or
 any other additional pay, income or fringe benefits.

PROOF OF GOOD HEALTH

You may be required to provide proof of good health if you are currently enrolled in the Plan and you change
or add coverage during annual enrollment or due to a qualified life event and:
 you want to increase your supplemental life insurance by more than one option level (for example, from
no coverage to more than one time pay or one time pay to three times pay), or
 the amount of coverage you are requesting exceeds $500,000.
You will also need to provide proof of good health if you are a new hire or are newly eligible electing
supplemental life insurance for the first time AND the amount of coverage you elect exceeds $500,000.

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ACCELERATED DEATH BENEFIT

If you are diagnosed as being terminally ill and have a life expectancy of less than 12 months, you may request
that a portion of your life insurance benefit be paid as an accelerated death benefit. This means you request
an amount to be paid to you now, instead of your beneficiary at the time of your death. You may exercise this
option only once. You must submit proof of your terminal illness and upon approval by the insurance
company, an accelerated death benefit will be paid to you in a lump sum. The amount of life insurance must
be at least $10,000 to be eligible for this benefit.
Receiving any benefits in accordance with this provision will reduce the life insurance benefits payable upon
death. Life insurance benefits payable upon death will be calculated based on the amount of life insurance you
are eligible to receive without regard to accelerated benefits minus any accelerated benefits actually paid.
Benefits received under this provision may be taxable. Consult your tax advisor for further information.
Your request for an accelerated death benefit cannot exceed 80% of the in-force life insurance amount, and is
subject to a minimum of $3,000 and a maximum of $500,000.
Your insurance will continue for up to six months if you are terminally ill as long as:
 the required premium is paid, and
 the group Insurance policy remains in force.
Continued insurance will be subject to any reductions provided in any part of this Plan.
Proof of your terminal illness must be provided by an attending physician licensed to practice in the United
States. There may be additional requirements under the accelerated death benefit. Call Hartford at (800) 523-
2233 for more information or refer to the plan documents for additional details.

CONVERSION
If your Life Insurance or AD&D coverage terminates for any reason, you may arrange with the insurance
company to continue insurance under an individual policy without a medical examination. The amount you
may convert cannot be greater than the amount you were insured for under the policy less any amount of life
insurance for which you may become eligible under any group life insurance policy issued or reinstated within
31 calendar days of termination. You may elect the standard form of individual policy issued by the insurance
company at the time of termination. To secure an individual policy under the Conversion Privilege, the
insurance company must receive your completed application within 31 calendar days after you lose your
coverage.
If your death should occur in the 31 calendar day period during which you were entitled to convert your Group
Life Insurance, the amount which you were entitled to convert will be paid as a death benefit under the Group
Life Policy, whether or not application has been made and the first premium paid for the individual policy.

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 Life and Accidental Death & Dismemberment Plan

PORTABILITY
If you experience a qualifying life event that results in a loss of coverage, an application may be made for a
Term Life policy without providing proof of good health for the Supplemental Life insurance portion only
(amount in excess of one times pay), in increments of 50%/75%/100% of the amount of insurance in place
before loss of coverage to a maximum of $250,000. Application must be made within 31 calendar days of the
date of lost coverage.
Employees may combine the portability and conversion options, however amounts converted may not be
ported and amounts ported may not be converted. For example, you may convert one times pay (the basic
amount) and buy a portability policy for the amount in excess of one times pay (the supplemental amount).
If you remain actively enrolled and your Life insurance coverage is reduced under the Age Reduction and any
Plan provisions, such as a reduction in benefits due to a reduction in hours, you may elect to convert and/or
port the reduced amount under the above provisions.
A notice of your portability and conversion options will be mailed to your home address. You are responsible
for requesting coverage within the 31-day window even if do not receive this notice.

HOW AD&D INSURANCE WORKS

This coverage pays a benefit of one times your Basic Annual Earnings (rounded to the nearest $1,000) to your
beneficiary if you die due to accidental injury. Your Basic Annual Earnings is determined as of your date of hire.
Each January 1, your coverage is adjusted to reflect your Basic Annual Earnings as of the previous October 1.
If you are seriously injured, you will receive benefits for losses as the result of a bodily injury sustained directly
and independently of all other causes.
Injury means a bodily injury occurring while you are covered under the Plan and results:
 directly from an accident, and
 independent of all other causes.
A Loss from the following is not considered to be resulting from an injury and is not covered under the AD&D
provisions of the Plan:
 sickness or disease, except a pus-forming infection which occurs through an accidental wound, or
 medical or surgical treatment of a sickness or disease.

ACTIVELY AT WORK PROVISION

If you change Plan options during annual enrollment or due to a qualified status change and you are absent
from work on the date your coverage begins, your change will not become effective until you are actively at
work for one full day. However, if you are not actively at work on that date, any increased amount of coverage
will become effective on the date you return to your regularly scheduled hours.

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 Life and Accidental Death & Dismemberment Plan

Actively at work means the use of time and energy in the service of UHS:
 at the normal place of business,
 on a regular basis, and
 when you are not disabled and you are working your regularly scheduled hours.
If you are actively at work as defined above, on your last regular working day, you will be deemed to be active
work:
 on each day of a regular paid vacation, or
 on a regular non-working day on which you are not disabled.

HOW AD&D BENEFITS ARE PAID

For loss of: Percentage of
Benefit Payable1
Life 100%
Both Hands, Both Feet, or Sight of Both Eyes 100%
One Hand and One Foot 100%
Speech and Hearing 100%
(Both ears)
Either Hand or Foot and Sight of One Eye 100%
Quadriplegia 100%
(Total paralysis of both upper and lower limbs)
Paraplegia 75%
(Total paralysis of both lower limbs or both upper limbs)
Triplegia 75%
(Total paralysis of three limbs)
Either Hand or Foot 50%
Sight of One Eye 50%
Speech or Hearing 50%
(Both ears)
Hemiplegia 50%
(Total paralysis of upper and lower limbs on one side of the body)
Uniplegia 25%
(Total paralysis of one lower limb or one upper limb)
Thumb and Index Finger of Same Hand 25%
Hearing in One Ear 25%
1 More than 100% of principal sum will not be paid to any one person.

If you sustain more than one of the losses described above as a result of any one accident, more than 100% of
principal sum will not be paid to any one person.

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 Life and Accidental Death & Dismemberment Plan

Paralysis must be determined by competent medical authority to be permanent, complete, and irreversible.
Proof of total paralysis may be required by the insurance company on a periodic basis.

WHAT’S NOT COVERED

No AD&D coverage is provided and no payment is made for any loss resulting in whole or in part from, or
contributed to by, or as a natural and probable consequence of any of the following policy exclusions even if
the proximate or precipitating cause of the loss is an accidental bodily injury.
 Suicide or any attempt at suicide or intentionally self-inflicted injury or any attempt at intentionally self-
inflicted injury.
 Declared or undeclared war or any act of declared or undeclared war.
 Full-time active duty in the Armed Forces, of any country or international authority except Reserve
National Guard Service. (Unearned premium for any period for which the Insured Person is not covered
due to his or her active duty status will be refunded.) Loss caused while on short-term National Guard or
reserve duty for regularly scheduled training purposes is not excluded.
 Injury sustained while on any aircraft except a civil or public aircraft, or military transport aircraft; or on
any aircraft: (a) as a pilot, crewmember or student pilot; as a flight instructor or examiner; (b) or if it is
owned, operated or leased by or on behalf of the Policyholder; or (c) being used for tests, experimental
purposes, stunt flying, racing or endurance tests.
 The Insured being under the influence of any narcotic unless taken under the advice of and as specified by
a physician.
 Sickness, or disease, mental incapacity or bodily infirmity whether the loss results directly or indirectly
from any of these.
 The Insured’s commission of or attempt to commit a felony.
 The Insured being under the influence of intoxicants while operating any vehicle or means of
transportation or conveyance.

ADDITIONAL BENEFITS
Under certain circumstance, you may be entitled to an additional benefit under the Plan, as described here.

ACCIDENT HOSPITAL INCOME BENEFIT

If as a result of an accidental injury you are confined to a hospital within 30 calendar days of the date of such
accident, the Plan will pay a benefit after five calendar days of confinement in the amount of the lesser of
$3,000 or 1% of your principal sum per month of inpatient confinement. No payment will be made for a
confinement that occurs more than two years after the date of the accident.

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CHILD EDUCATION BENEFIT

For dependent children under age 23 who are full-time students in any institution of higher learning above
grade 12, or who are in grade 12 and enroll within 365 days after your death, the Plan will pay the lesser of
(a) the school’s actual tuition (exclusive of room and board), (b) 5% of the principal sum, or (c) $5,000. The
benefit will be paid each year of continuous enrollment for a maximum of four years.

HIV OCCUPATIONAL ACCIDENT BENEFIT

The Plan will pay an HIV Benefit if, while insured for this benefit, you suffer an accidental bodily Injury in the
performance of your duties, which causes you to acquire and test positive within one year of such accident for
Human Immunodeficiency Virus (HIV). The accident must occur during the course of your employment with
UHS and while insured under this Plan. An HIV Benefit will be paid equal to $1,000 per month. The benefit will
continue for 60 consecutive months or until you die, whichever occurs first. The HIV Benefit will be in addition
to any other benefit that may be payable because of the accident.
The benefit is payable if you test positive for HIV within 365 days of the occupational incident if, within 72
hours of the occupational incident, you 1) report the accident to UHS and the Plan in writing; and 2) undergo a
Food and Drug Administration (FDA) approved preliminary screening test for HIV which indicates negativity
with respect to the presence of any antibodies or antigens to such disease.

REHABILITATION BENEFIT
Upon a covered accidental dismemberment or accidental paralysis, the Plan will pay for rehabilitative
expenses incurred within two years, up to a maximum of $5,000.

REPATRIATION OF REMAINS BENEFITS

If you die due to injury while outside a 100-mile radius from your residence, the Plan will pay for covered
expenses reasonably incurred to a maximum of $50,000 to return your body to your primary residence.

SEAT BELT/AIR BAG BENEFIT

If you die in an accident while operating or riding as a passenger in an automobile and wearing a properly
fastened, original, factory-installed seat belt, the Plan will pay the lesser of 10% of the principal sum up to a
maximum of $25,000. The minimum benefit is $1,000. If a seat belt benefit is payable, an air bag benefit may
also be payable in a matching amount.

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 Life and Accidental Death & Dismemberment Plan

SPOUSE EDUCATION BENEFIT

For your surviving spouse, the Plan will pay the lesser of (a) the expense incurred for occupational training,
(b) 5% of the principal sum or (c) $5,000. Your surviving spouse must enroll in occupational training within one
year of your death.

GENERAL LIFE AND AD&D INFORMATION

The following describes general provisions of the Plan. For specific information about Plan provisions, call
Hartford at (800) 523-2233 or refer to the plan documents.

EFFECTIVE DATE OF INSURANCE

Your insurance will become effective 30 calendar days following your date of employment. If you are absent
from work due to illness or injury on the date your coverage is to begin, your coverage will begin when you
return to active work. If you are required to submit Evidence of Insurability to obtain additional insurance, the
effective date of any approved coverage may be delayed. You will be notified if a different date of coverage
applies.

POLICY AND CERTIFICATE

The complete terms of the insurance coverage are as set forth in the policies issued by the insurance
company. Call Harford Life Insurance Company at (800) 523-2233 for additional information.

ASSIGNMENTS
The provisions of this policy permits you to assign your interests in the insurance coverage to another party. If
you make any assignment of your insurance, it must be:
 in writing, and
 properly recorded by the insurance company.
UHS will not be responsible for:
 the effect of the assignment, or
 whether or not the assignment is valid.
In view of the complexity in the application of the law governing such transfer, you are advised to consult with
your tax and legal advisor(s) before making any assignment of your rights under this policy.

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 Life and Accidental Death & Dismemberment Plan

DESIGNATING BENEFICIARIES
If you die, your benefit will be paid to your beneficiary. You may choose any person(s) to be your beneficiary.
You can change your beneficiary at any time. If you decide to designate a minor as beneficiary, consult with
legal counsel before designating a minor as your beneficiary.
If at your death there is no named beneficiary, or if no designated beneficiary is then living, the proceeds will
be payable to the duly qualified executors or administrator of your estate, except that the insurance company
may, in such case, at its discretion, pay the proceeds to your wife or husband, if living; otherwise, to your
surviving children or legally adopted children, if any, equally; otherwise, to your parents equally or the
survivor. The insurance company may, at its discretion, make payment in a lump sum up to $250 or the
amount required by the state whose laws govern the Plan, to any person appearing to the insurer to have
incurred funeral or other expenses incident to your last illness or death.
Any amount payable to a beneficiary who is a minor or is otherwise incapable of giving a valid release for any
payment due, may be paid to the legally appointed guardian of such beneficiary; or if there is no such
guardian, to such person or institution as has in the opinion of the insurance company assumed the custody
and principal support of such beneficiary.

CLAIMS
Use this information to file claims for benefits under the Plan.

FILING A CLAIM
A written claim must be filed with the insurance company within 30 days of your death or accidental injury. If
notice cannot be given within that time, it must be given as soon as reasonably possible. UHS may assist your
beneficiary in filing a claim.
Claims for benefits normally will be paid when the insurance company receives proof of an employee's death.
This proof should be furnished to the insurance company as soon as reasonably possible.

IF A CLAIM IS DENIED
If the insurance company denies the claim, in whole or in part, your beneficiary or authorized representative is
entitled to have the insurance company review its claim decision. However, if your beneficiary still feels a
claim is unfairly denied, he or she has certain rights under federal law.
For additional information, refer to “Non-Health Claim Filing and Appeal Procedures” on page 176 of the “Plan
Administration Information” section of this SPD.

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 Life and Accidental Death & Dismemberment Plan

WHEN COVERAGE ENDS

Coverage will end:
 on the last day of the pay period following the date you terminate employment, retire, or cease to be a
member of an eligible class
 if you cease to pay premiums
 The date that your coverage is terminated by amendment of the Plan, by whole or partial termination of
the Plan, by termination of the Master Policy, or by discontinuance of contributions by UHS.

Effective January 1, 2024 101

 Dependent Life Insurance
Voluntary dependent life insurance offers extra term life protection for your
eligible dependents at group rates through the convenience of payroll deductions.
You may choose the amount of life insurance that fits the needs of your legal
spouse and your eligible children.
If you and your spouse both work for UHS, only one of you can elect dependent
life insurance coverage for your children. However, you may both elect to
purchase spouse life insurance coverage.

In this Section
Dependent Life Insurance at a Glance ........................................................................................................................................... 103
Eligible Dependents ....................................................................................................................................................................... 103
How to Apply ................................................................................................................................................................................ 103
Pre-Existing Condition Limitation ................................................................................................................................................... 103
Cost of Coverage ........................................................................................................................................................................... 104
General Plan Provisions ................................................................................................................................................................. 104
Keeping Your Coverage in Force ..................................................................................................................................................... 104
Portability ....................................................................................................................................................................................... 104
Conversion ...................................................................................................................................................................................... 104
Designating Beneficiaries ................................................................................................................................................................ 105
Accelerated Death Benefit .............................................................................................................................................................. 105
Exclusion ......................................................................................................................................................................................... 105
Claims............................................................................................................................................................................................ 106
Filing a Claim ................................................................................................................................................................................... 106
If a Claim Is Denied ......................................................................................................................................................................... 106
When Coverage Ends ..................................................................................................................................................................... 106

Effective January 1, 2024 102

 Dependent Life Insurance

DEPENDENT LIFE INSURANCE AT A GLANCE

The following chart summarizes your benefits under the Plan.
Spouse Only Coverage Options You can purchase coverage equal to: $10,000, $25,000, $35,000, $100,000, or $250,000

Child(ren) Only Coverage Options

Option 1 $2,000 per child

Option 2 $10,000 per child

Option 3 $15,000 per child

Spouse and Child(ren) Coverage Options

Option 1 Spouse $10,000, Child(ren) $2,000 each

Option 2 Spouse $25,000, Child(ren) $10,000 each

Option 3 Spouse $35,000, Child(ren) $15,000 each

Option 4 Spouse $100,000, Child(ren) $15,000 each

Option 5 Spouse $250,000, Child(ren) $15,000 each

ELIGIBLE DEPENDENTS
Dependent child(ren) eligibility begins at live birth and ends at age 19 (or age 23 for full-time students). Other
eligibility and Plan requirements apply; contact the insurance carrier, Hartford, at (800) 523-2233 for more
information or refer to the plan documents for additional details. Your paid premium will insure all your
eligible children, regardless of the number of children you have.

HOW TO APPLY
You are eligible to enroll as a new hire, when you change to a benefit-eligible status and during the annual
enrollment period. If you are newly hired, your coverage will become effective 30 calendar days after your
date of hire. If you are a newly eligible employee, you may enroll 30 calendar days after the day of your status
change. Annual enrollment changes are effective the following January 1. If you are not regularly performing
the duties of your occupation on the effective date of insurance, the effective date will be first of the month
following the date you return to your regular duties.

PRE-EXISTING CONDITION LIMITATION

If you are covering a dependent for the first time, or if you increase the amount of his or her coverage during
annual enrollment or upon a Qualified Life Event, benefits are not paid for death resulting from pre-existing

Effective January 1, 2024 103

 Dependent Life Insurance

conditions. A pre-existing condition is a condition for which medical treatment, care, diagnosis, or advice was
received within 3 months before the coverage effective date. This does not apply once coverage has been in
force for 12 months.

COST OF COVERAGE
While rates may not be increased on an individual basis, UHS reserves the right to increase rates on a group
basis. Rates are aged based and will increase upon attainment of certain ages. You may access your
personalized rates on your enrollment record. For more information, refer to the "2024 UHS All BENEFITS - All
Locations - Cost Sheet" available in your enrollment materials or by contacting your Human Resources
Department.

GENERAL PLAN PROVISIONS

Call Hartford at (800) 523-2233 for information about the Plan or refer to the plan documents for additional
details.

KEEPING YOUR COVERAGE IN FORCE

Dependent life insurance is 100% employee contributory. Your dependent coverage continues provided you
remain an eligible employee and your contributions continue. Refer to “When Coverage Ends” on page 106 for
other reasons your coverage may terminate.

PORTABILITY
If you and/or your dependents have a qualifying event and lose coverage, it may be continued if portability is
elected. This feature allows for the same coverage that was in place when actively covered, provided
premiums are paid directly to the insurance company. See “Qualified Life Events” on page 5 in the “Eligibility
and Enrollment” section of this SPD for more information. The portability feature is not available if the Master
Policy terminates.

CONVERSION
If your Dependent Life Insurance terminates for any reason, you may arrange with the insurance company to
continue insurance under an individual policy without a medical examination. The amount you may convert
cannot be greater than the amount for which your dependent was insured under the policy less any amount of
life insurance for which your dependent may become eligible under any group life insurance policy issued or
reinstated within 31 calendar days of termination. You may elect the standard form of individual policy issued
by the insurance company at the time of termination. To secure an individual policy under the Conversion
Privilege, the insurance company must receive your completed application within 31 calendar days after you
lose your coverage.

Effective January 1, 2024 104

 Dependent Life Insurance

If your covered dependent’s death should occur in the 31-calendar day period during which you were entitled
to convert your Group Life Insurance, the amount which you were entitled to convert will be paid as a death
benefit under the Group Life Policy, whether or not application has been made and the first premium paid for
the individual policy.

DESIGNATING BENEFICIARIES
In the event your covered spouse or children die, you (or your estate) are the beneficiary of any insurance
proceeds.

ACCELERATED DEATH BENEFIT

If your covered spouse or child is diagnosed as being terminally ill and has a life expectancy of less than 12
months, you may request that a portion of the life insurance benefit be paid as an accelerated death benefit.
This means you request an amount to be paid to you now, instead of at the time of your spouse or child’s
death. You may exercise this option only once. You must submit proof of your spouse or child’s terminal illness
and upon approval by the insurance company, an accelerated death benefit will be paid to you in a lump sum.
The amount of life insurance must be at least $10,000 to be eligible for this benefit.
Receiving any benefits in accordance with this provision will reduce the life insurance benefits payable upon
death. Life insurance benefits payable upon death will be calculated based on the amount of life insurance in
force without regard to accelerated benefits minus any accelerated benefits actually paid. Benefits received
under this provision may be taxable. Consult your tax advisor for further information.
Your request for an accelerated death benefit cannot exceed 80% of the in force life insurance amount, and is
subject to a minimum of $3,000 and a maximum of $500,000.
The spouse or child insurance coverage will continue for up to six months as long as:
 the required premium is paid; and
 the group Insurance policy remains in force.
Continued insurance will be subject to any reductions provided in any part of this Plan.
Proof of the terminal illness must be provided by an attending physician licensed to practice in the United
States. There may be additional requirements under the accelerated death benefit. Call Hartford at (800) 523-
2233 for more information or refer to the plan documents for additional details.

EXCLUSION
For Plan exclusions, call Hartford at (800) 523-2233 for more information and refer to plan documents for
additional plan details.

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 Dependent Life Insurance

CLAIMS
Use this information to file claims for benefits under the Plan.

FILING A CLAIM
A written claim must be filed with the insurance company within 30 days of your dependent’s death or
accidental injury. If notice cannot be given within that time, it must be given as soon as reasonably possible.
UHS will assist you in filing a claim.

IF A CLAIM IS DENIED
If the insurance company denies the claim, in whole or in part, you are entitled to have the insurance company
review its claim decision. However, if you still believe a claim is unfairly denied, you have certain rights under
federal law.
For additional information, refer to “Non-Health Claim Filing and Appeal Procedures” on page 176 in the “Plan
Administration Information” section of this SPD.

WHEN COVERAGE ENDS

Coverage for you and your dependents will end:
 on the last day of the pay period following the date you terminate employment, retire, or cease to be a
member of an eligible class
 if you cease to pay premiums
 for dependents, the date on which a dependent is no longer eligible for dependent coverage
 the date that your coverage is terminated by amendment of the Plan, by whole or partial termination of
the Plan, by termination of the Master Policy, or by discontinuance of contributions by UHS.

Effective January 1, 2024 106

 Supplemental AD&D
Supplemental AD&D is a voluntary benefit through The Hartford Life and Accident
Insurance Company that offers coverage to help you and your family with some of
the financial consequences of an accident. The Plan offers full 24-hour accident
insurance anywhere in the world, on or off the job, on business, on vacation, or at
home.

In this Section
Supplemental AD&D insurance at a Glance ................................................................................................................................... 108
Employee Only Plan ........................................................................................................................................................................ 108
Employee and Family Plan .............................................................................................................................................................. 108
Eligibility.......................................................................................................................................................................................... 108
Eligible Dependents ........................................................................................................................................................................ 109
Enrollment .................................................................................................................................................................................... 109
Effective Date of Coverage ............................................................................................................................................................. 109
General Information ...................................................................................................................................................................... 110
Age Reductions ............................................................................................................................................................................... 110
Basic Annual Earnings ..................................................................................................................................................................... 110
How Benefits Are Paid ................................................................................................................................................................... 110
Additional Benefits ........................................................................................................................................................................ 111
What's Not Covered ...................................................................................................................................................................... 114
Claims............................................................................................................................................................................................ 115
Filing a Claim ................................................................................................................................................................................... 115
If a Claim Is Denied ......................................................................................................................................................................... 115
When Coverage Ends ..................................................................................................................................................................... 115
Conversion ...................................................................................................................................................................................... 116

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 Supplemental AD&D

SUPPLEMENTAL AD&D INSURANCE AT A GLANCE

EMPLOYEE ONLY PLAN

You can choose from the following Benefit Amounts and you will be insured regardless of your health history.
The amount you select cannot exceed 10 times your Basic Annual Earnings.
 $25,000
 $50,000
 $75,000
 $100,000
 $200,000
 $300,000.

EMPLOYEE AND FAMILY PLAN

If you want to insure your eligible spouse and/or dependent child(ren) under the Family Plan, the amount of
insurance applicable to members of the family is based on the composition of the family at the time of loss
and expressed as a percentage of your Selected Benefit Amount:
If, at the Time of Loss, the Family Consists of… The Benefit Is This Percentage of Your Selected Benefit Amount…
Employee, Spouse and Dependent Child(ren) Employee: 100%
Spouse: 60%
Each Child1: 20%
Employee and Spouse Employee: 100%
(No dependent child(ren)) Spouse: 60%
Employee and Dependent Child(ren) Employee: 100%
(No spouse) Each Child1: 20%
1 The principal sum for any one child cannot exceed the lesser of the amount calculated or $60,000.

See “Age Reductions” on page 110 for more information.

ELIGIBILITY
You are eligible for coverage 30 days following the date you begin employment or change to a benefit-eligible
status, provided you are regularly scheduled to work a minimum of 30 hours per week and you are not
covered by a collective bargaining agreement, unless the agreement provides for such coverage. Eligibility for
employees scheduled to work less than 30 hours per week may vary by UHS subsidiary location.
Check with your Human Resources Department to confirm your eligibility. You must enroll to be covered.

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 Supplemental AD&D

ELIGIBLE DEPENDENTS
Eligible dependents are defined as:
 Your lawful spouse in accordance with federal law and regulations.
 Your unmarried children from live birth to age 19 (or age 23 for full-time students).
Please Note: Other eligibility and Plan requirements apply; please call Hartford at (800) 523-2233 for more
information or refer to the plan documents for additional details.

ENROLLMENT
You must enroll to be covered. You must enroll your eligible dependents at the same time you enroll yourself.
If you do not make active elections when eligible to do so, you must wait until a qualifying life event or until
the next annual enrollment.

EFFECTIVE DATE OF COVERAGE

If you are a newly eligible employee, your coverage will become effective 30 calendar days after your date of
hire or date of status change. You are also eligible to enroll during the annual enrollment period each year; the
effective date will be the following January 1. If you are not regularly performing the duties of your occupation
on the effective date of insurance, the effective date will be the date your return to your work and your
regular duties.

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 Supplemental AD&D

GENERAL INFORMATION

AGE REDUCTIONS
After you obtain age 70, the Plan reduces the benefit you will be paid for a covered accident to reflect your
age at your prior policy anniversary date. As a result, your benefit will be paid as follows:
If Your Age on the Date of the covered accident Is … Your Benefit Is Reduced to …
70 80% of Selected Benefit Amount
75 70% of Selected Benefit Amount
80 65% of Selected Benefit Amount
85 60% of Selected Benefit Amount

If your covered dependent is age 70 or older at the time of a covered accident, Plan benefits payable to that
dependent (other than insured family members' Accidental Death and Dismemberment benefits) will be based
on your reduced Selected Benefit Amount.

BASIC ANNUAL EARNINGS

Your coverage for the calendar year is determined by your Basic Annual Earnings. When you first enroll for
coverage, your Basic Annual Earnings is determined as of your date of hire. Each January 1, your coverage is
adjusted to reflect your Basic Annual Earnings in effect on the previous October 1.
Basic Annual Earnings does not include:
 bonuses,
 settlement pay,
 overtime pay, or
 any other additional pay, income or fringe benefits.

HOW BENEFITS ARE PAID

If bodily injuries result in death or dismemberment within one year of the date of the covered accident, the
Plan will pay as follows:
For loss of: Percentage of Benefit
Payable1
Life 100%
Both Hands, Both feet, or Sight of Both Eyes 100%
One Hand and One Foot 100%
Speech and Hearing 100%
(Both ears)

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 Supplemental AD&D

For loss of: Percentage of Benefit

Payable1
Either hand or foot and sight of one eye 100%
Quadriplegia 100%
(Total paralysis of both upper and lower limbs)
Paraplegia 75%
(Total paralysis of both lower limbs or both upper limbs)
Triplegia 75%
(Total paralysis of three limbs)
Either Hand or Foot 50%
Sight of One Eye 50%
Speech or Hearing 50%
(Both ears)
Hemiplegia 50%
(Total paralysis of upper and lower limbs on one side of the body)
Uniplegia 25%
(Total paralysis of one lower limb or one upper limb)
Thumb and Index Finger of Same Hand 25%
Hearing in One Ear 25%
1 More than 100% of principal sum will not be paid to any one person.

Injury means a bodily injury occurring while you or your dependent are covered under the Plan and results:
 directly from an accident, and
 independent of all other causes.
A Loss from the following is not considered to be resulting from injury and is not covered under the Plan:
 sickness or disease, except a pus-forming infection which occurs through an accidental wound, or
 medical or surgical treatment of a sickness or disease.

ADDITIONAL BENEFITS

Accident Hospital Income Benefit

If as a result of an accidental injury you are confined to a hospital within 30 calendar days of the date of such
accident, the Plan will pay a benefit after five calendar days of confinement in the amount of the lesser of
$3,000 or 1% of your principal sum per month of inpatient confinement. No payment will be made for a
confinement that occurs more than two years after the date of the accident.

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 Supplemental AD&D

Child Education Benefit

For dependent children under age 23 who are full-time students in any institution of higher learning above
grade 12, or who is in grade 12 and enrolls within 365 days after your death, the Plan will pay the lesser of
(a) the school’s actual tuition (exclusive of room and board), (b) 5% of the principal sum, or (c) $5,000. The
benefit will be paid each year of continuous enrollment for a maximum of four years.

Common Disaster Benefit

If you have family coverage and you and your spouse both suffer an accidental death in the same accident or
in separate accidents which occur within 24 hours of each other, your spouse’s principal sum is increased to
equal 100% of your principal sum up to the maximum benefit payable under the Plan.

Continuation of Medical Coverage (COBRA) Benefit

Upon your accidental death, the Plan will cover the cost of the premium charged for continued medical, dental
or vision coverage (COBRA Benefits) provided by UHS for covered dependents insured continuously from the
date of your accident to the date of your death. The benefit is payable for a maximum of three consecutive
years up to the lesser of 1) the actual cost of the premium charged, 2) 5% of the principal sum, or 3) $3,000.
The minimum benefit is $600. This benefit runs concurrent with the COBRA continuation period of your
dependent(s).

Day Care Benefit

For dependent children under age 13 who are enrolled in a day care center on the date of your death, the Plan
will pay an annual benefit equal to the lesser of (a) the amount charged by the day care center for that year,
(b) 3% of the principal sum, or (c) $3,000. The minimum amount is $500. Benefits are payable for a maximum
of four years or the date your child reaches age 13, whichever occurs first.

Dependent Child Dismemberment Benefit

If an insured dependent child suffers an accidental dismemberment or an accidental paralysis for which an
accidental dismemberment benefit or a paralysis benefit is payable under the Plan, the Plan will pay an
additional benefit to or on behalf of your dependent. This coverage runs concurrent with the COBRA
continuation period of your dependent(s).

Emergency Evacuation Benefit

The Plan will pay for covered emergency evacuation expenses if you suffer an injury or emergency sickness
requiring emergency evacuation while you are outside a 100-mile radius from your primary residence.

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 Supplemental AD&D

HIV Occupational Accident Benefit

The Plan will pay an HIV Benefit if, while insured for this benefit, you suffer an accidental bodily Injury in the
performance of your duties, which causes you to acquire and test positive within one year of such accident for
Human Immunodeficiency Virus (HIV). The accident must occur during the course of your employment with
UHS and while insured under this Plan. An HIV Benefit will be paid equal to $1000 per month. The benefit will
continue for 60 consecutive months or until you die, whichever occurs first. The HIV Benefit will be in addition
to any other benefit that may be payable because of the accident.
The benefit is payable if you test positive for HIV within 365 days of the occupational incident if, within 72
hours of the occupational incident, you 1) report the accident to UHS and the Plan in writing; and 2) undergo a
Food and Drug Administration (FDA) approved preliminary screening test for HIV which indicates negativity
with respect to the presence of any antibodies or antigens to such disease.

Paralysis Benefit
If you sustain quadriplegia, paraplegia, hemiplegia, or uniplegia within 365 days of the date of a covered
accident, the Plan will pay the percentage of your benefit shown below. The maximum benefit payable will not
exceed the full benefit amount. Paralysis must be determined by competent medical authority to be
permanent, complete, and irreversible. Proof of total paralysis may be required by the insurance carrier on a
periodic basis.
Quadriplegia 100%
(Total paralysis of both upper and lower limbs)
Paraplegia 75%
(total paralysis of both lower limbs)
Triplegia 75%
(Total paralysis of three limbs)
Hemiplegia 50%
(Total paralysis of upper and lower limbs on one side of the body)
Uniplegia 25%
(Total paralysis of one lower limb or one upper limb)

Rehabilitation Benefit
Upon a covered accidental dismemberment or accidental paralysis, the Plan will pay for rehabilitative
expenses incurred within two years, up to a maximum of $5,000.

Repatriation of Remains Benefits

If you die due to injury while outside a 100-mile radius from your primary residence, the Plan will pay for
covered expenses reasonably incurred to return your body to the primary residence.

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 Supplemental AD&D

Seatbelt/Air Bag Benefit

If you suffer an accidental death while you are operating or riding as a passenger in an automobile and
wearing a properly fastened, original, factory-installed seat belt, the Plan will pay the lesser of 10% of the
principal sum or $25,000 in addition to the principal sum, with double benefits paid for air bag use. The
minimum benefit is $1,000.

Spouse Education Benefit

For the surviving spouse, the Plan will pay the lesser of (a) the expense incurred for occupational training,
(b) 5% of the principal sum or (c) $5,000. Your surviving spouse must enroll in occupational training within one
year of your death.

Survivor Income Benefit

If you or your spouse dies as a result of a covered accident, the Plan will pay you, your spouse or surviving
children, as applicable and if any, 3% of the applicable benefit amount for twelve consecutive months.

WHAT'S NOT COVERED

No coverage will be provided under the Plan and no payment will be made for any loss resulting in whole or in
part from, or contributed to by, or as a natural and probable consequence of, any of the following excluded
risks, even if the proximate or precipitating cause of the loss is an accidental bodily injury:
 Suicide or any attempt at suicide or intentionally self-inflicted injury or any attempt at intentionally self-
inflicted injury.
 Declared or undeclared war or any act of declared or undeclared war.
 Full-time active duty in the Armed Forces, of any country or international authority except Reserve
National Guard Service. (Premiums for any period for which the Insured Person is not covered due to his or
her active duty status will be refunded.) (Loss caused while on short-term National Guard or reserve duty
for regularly scheduled training purposes is not excluded.)
 Injury sustained while on any aircraft except a civil or public aircraft, or military transport aircraft; or on
any aircraft: (a) as a pilot, crewmember or student pilot; as a flight instructor or examiner; (b) if it is
owned, operated or leased by or on behalf of the policyholder; or (c) being used for tests, experimental
purposes, stunt flying, racing or endurance tests.
 The Insured being under the influence of any narcotic unless taken under the advice of and as specified by
a physician.
 Sickness, or disease, mental incapacity or bodily infirmity whether the loss results directly or indirectly
from any of these.
 The insured’s commission of or attempt to commit a felony.

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 Supplemental AD&D

 The insured being under the influence of intoxicants while operating any vehicle or means of
transportation or conveyance.

CLAIMS
Use this information to file claims for benefits under the Plan.

FILING A CLAIM
A written claim must be filed with the insurance company within 30 days of your death or accidental injury. If
notice cannot be given within that time, it must be given as soon as reasonably possible. UHS may assist your
beneficiary in filing a claim.
Claims for benefits normally will be paid when the insurance company receives proof of an employee's death.
This proof should be furnished as soon as reasonably possible.

IF A CLAIM IS DENIED
If the insurance company denies the claim, in whole or in part, your beneficiary or authorized representative is
entitled to have the insurance company review its claim decision.
For additional information, refer to “Non-Health Claim Filing and Appeal Procedures” on page 176 in the “Plan
Administration Information” section of this SPD.

WHEN COVERAGE ENDS

Coverage for you and your dependents will end:
• on the last day of the pay period following the date you terminate employment, retire, or cease to be a
member of an eligible class
• if you cease to pay premiums
• for dependents, the date on which a dependent is no longer eligible for dependent coverage
• The date that your coverage is terminated by amendment of the Plan, by whole or partial termination
of the Plan, by termination of the Master Policy, or by discontinuance of contributions by UHS.

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 Supplemental AD&D

CONVERSION
If you or your dependents cease to be eligible for coverage and the policy has not terminated, you may
convert your insurance to coverage under an individual policy at the premium and coverage provisions
available from the insurance company at the time you make application. You must apply for the conversion
policy and pay the first premium within 31 calendar days after termination of your group coverage. Medical
certification is not required to obtain a conversion policy. Coverage will be the amount of principal sum on the
date of conversion, subject to a $25,000 minimum and $500,000 maximum. Reduced amounts apply if you are
age 70 or older. See “Age Reductions” on page 110 for more information.

Effective January 1, 2024 116

 Business Travel Accident Insurance
Business Travel Accident insurance offers 24-hour accident protection anywhere in
the world while you are traveling on Universal Health Services, Inc. (UHS) business.
It provides benefits to your beneficiary in the event of your death or to you in the
event of serious bodily injury.

In this Section
Eligibility........................................................................................................................................................................................ 117
Enrollment .................................................................................................................................................................................... 117
How Benefits Are Paid ................................................................................................................................................................... 118
Aggregate Limit of Liability ............................................................................................................................................................. 119
What's Not Covered ...................................................................................................................................................................... 119
Designating Beneficiaries .............................................................................................................................................................. 119
Claims............................................................................................................................................................................................ 119
Filing a Claim ................................................................................................................................................................................... 119
If a Claim Is Denied ......................................................................................................................................................................... 120
When Coverage Ends ..................................................................................................................................................................... 120

ELIGIBILITY
You are eligible for this plan if you are an active full-time employee of UHS and the subsidiaries of UHS.
Eligibility for coverage also includes all eligible, lawful spouses and dependent children who are traveling with
the employee at the direction and expense of the Policyholder, and who are not covered as an employee of
UHS.

ENROLLMENT
Your insurance will become effective on your first day of employment. You do not have to enroll to be
covered.

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 Business Travel Accident Insurance

HOW BENEFITS ARE PAID

The principal sum payable to all eligible employees is $100,000.
If you die as the result of accidental injury while traveling on UHS business, the principal sum will be paid to
the person you have named as your beneficiary. If you are dismembered as the result of accidental injury
while traveling on UHS business, the plan will pay benefits according to the following:
Loss Suffered Percentage of Benefit Payable
Life 100%
Both Hands, or Both Feet, or Sight of Both Eyes 100%
One Hand and One Foot 100%
One Hand and Sight of One Eye 100%
One Foot and Sight of One Eye 100%
Speech and Hearing in Both Ears 100%
Speech and Hearing in One Ear 75%
One Arm or One Leg 75%
One Hand or One Foot 50%
Sight of One Eye 50%
Speech or Hearing in Both Ears 50%
Thumb and Index Finger on Same Hand 25%
Hearing in One Ear 25%
One Thumb 10%

Injury means a bodily injury:

 which is sustained as a direct result of an unintended, unanticipated accident that is external to the body
and that occurs while the injured person’s coverage under the policy is in force; and
 which directly (independent of sickness, disease, mental incapacity, bodily infirmity or other cause) causes
a covered loss.
Only one amount, the largest to which you are entitled, is paid for all losses resulting from one accident.
The term "while traveling on UHS business" means on assignment by or at the direction of UHS for the
purposes of furthering UHS business. Such travel shall begin when you leave your residence or place of regular
employment, whichever occurs last and ends when you return to your residence or place of regular
employment, whichever occurs first.

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 Business Travel Accident Insurance

AGGREGATE LIMIT OF LIABILITY

If you are traveling with other covered persons of UHS, the aggregate limit under this policy for all losses
arising out of any one air travel accident is $10,000,000. In the event the aggregate limit is insufficient to pay a
full benefit to each covered person, then the amount paid will be in the proportion that one accident bears to
the total of all benefits.

WHAT'S NOT COVERED

The Business Travel Accident policy does not cover any loss resulting from:
 suicide or any attempt at suicide or intentionally self-inflicted injury
 war or any act of war, whether declared or undeclared war
 injury sustained while in the armed forces of any country or international authority
 injury sustained while on any aircraft, unless, and only to the extent, is specifically described in the policy
 injury sustained while on any aircraft engaged in an extra-hazardous aviation activity.
Other exclusions may apply as described under the policy.

DESIGNATING BENEFICIARIES
If you die, your accidental death benefit under this plan will be paid to your beneficiary. Your beneficiary is the
same beneficiary you establish for your Basic Life Insurance benefit.
In absence of a named beneficiary or if the beneficiary dies before you, the benefit will be payable under the
succession language in the policy.
If you decide to designate a minor as beneficiary, we suggest you first obtain legal advice. All benefits due, for
other than life as designated under the Schedule of Indemnities will be paid to you.

CLAIMS
Any indemnities payable will be paid in one lump sum.

FILING A CLAIM
A written claim must be filed within 30 calendar days of the date of the accident, or as soon as is reasonably
possible. UHS may assist you or your beneficiary in filing a claim.
Claims for benefits will be paid within a reasonable time period after the insurance company receives proof of
loss. Proof of loss must be filed within 90 calendar days, or as soon as is reasonably possible. Such proof of
claim may consist of a death certificate or medical records. Benefits may not be payable if you or your
beneficiary fails to present satisfactory claim information upon request.

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 Business Travel Accident Insurance

IF A CLAIM IS DENIED
If the insurance company denies the claim, in whole or in part, you, your beneficiary or authorized
representative is entitled to have the insurance company review its claim decision. If it is believed a claim was
unfairly denied, you, your beneficiary or representative has certain rights under federal law.
For additional information, refer to “Non-Health Claim Filing and Appeal Procedures” on page 176 in the “Plan
Administration Information” section of this SPD for more information.

WHEN COVERAGE ENDS

Your group insurance will terminate upon the earliest of the following events:
 the date you cease to be a member of an eligible class
 the day your employment terminates
 The date that your coverage is terminated by amendment of the Plan, by whole or partial termination of
the Plan, by termination of the Master Policy, or by discontinuance of contributions by UHS.

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 Short-Term Disability
Short-Term Disability (STD) is a voluntary benefit through The Hartford Life and
Accident Insurance Company. It pays you a portion of your pay if you cannot work
because of an illness or injury that lasts at least eight calendar days and is not job-
related. If you become ill or injured as a result of a job-related incident, you should
apply for Workers’ Compensation.

In this Section
Short-Term Disability at a Glance .................................................................................................................................................. 122
Eligibility........................................................................................................................................................................................ 122
Enrollment .................................................................................................................................................................................... 122
Actively at Work Provision .............................................................................................................................................................. 122
Cost of Coverage ........................................................................................................................................................................... 123
How STD Works ............................................................................................................................................................................. 123
General Plan Provisions ................................................................................................................................................................. 124
Benefit Waiting Period .................................................................................................................................................................... 124
No Waiver of Premium ................................................................................................................................................................... 124
Recurrent Disability ........................................................................................................................................................................ 124
Rehabilitative Employment ............................................................................................................................................................ 124
When Benefits End ......................................................................................................................................................................... 125
What’s Not Covered ...................................................................................................................................................................... 125
Claims............................................................................................................................................................................................ 125
Filing a Claim ................................................................................................................................................................................... 125
If a Claim Is Denied ......................................................................................................................................................................... 125
Filing an Appeal............................................................................................................................................................................... 126
When Coverage Ends ..................................................................................................................................................................... 126

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 Short-Term Disability

SHORT-TERM DISABILITY AT A GLANCE

You may elect either a 12-week or a 25-week STD Plan. If you have Long-Term Disability (LTD) coverage, your
STD election should correspond with your LTD Plan.
12-week Plan If you elected LTD with a 90 calendar day waiting period (Plan 90), you should elect the 12-week STD Plan
If you elected LTD with a 180 calendar day waiting period (Plan 180), you should elect either the 12-week or the
25-week Plan
25-week STD Plan, depending on the amount of Extended Leave Bank (ELB) and Paid Time Off (PTO) you have

STD benefits begin on the eighth calendar day and continue for either 12 or 25 weeks, depending on the Plan
you selected; however, you must use any ELB and PTO time before the STD Plan benefit begins, except where
prohibited by state or local laws.

ELIGIBILITY
You are eligible to enroll 30 days following the date you begin employment or change to a benefit-eligible
status, provided you are regularly scheduled to work a minimum of 30 hours per week and you are not
covered by a collective bargaining agreement, unless the agreement provides for such coverage. Eligibility for
employees scheduled to work less than 30 hours per week may vary by location.
Check with your Human Resources Department to confirm your eligibility. You must enroll to be covered by
any benefit plan.

ENROLLMENT
You are eligible to enroll without any restrictions on pre-existing conditions within 30 calendar days after your
date of hire. If you do not enroll within 30 calendar days of your first day of eligibility, the benefits you may
receive for pre-existing conditions will be limited, as follows:
 If you were diagnosed or received care for a condition in the 90 calendar days before the effective date of
your insurance, you will be covered for a disability due to that condition only if:
 you have not received treatment for your condition for 90 consecutive days while insured at the time
you become disabled, or
 you have been insured under this coverage for 365 days at the time you become disabled.
 If it is determined that your disability results from, or is caused or contributed to by a pre-existing
condition, you may receive STD benefits for up to a maximum of four weeks.

ACTIVELY AT WORK PROVISION

If you are absent from work due to accident or illness on the date your insurance would become effective, or a
change is due to be effective, the coverage or change will not become effective until you are Actively at Work
one full day.

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 Short-Term Disability

COST OF COVERAGE
Your contributions are post-tax through payroll deductions. The cost of coverage is based upon your age and
the level of coverage you elect. For more information, refer to the "2024 UHS All BENEFITS - All Locations -
Cost Sheet" available in your enrollment materials or by contacting your Human Resources Department.

HOW STD WORKS

STD coverage pays you a tax-free benefit of 60% of your Basic Annual Earnings, to a maximum benefit of
$1,000 per week. Depending on the time you have accrued in your Paid Time Off or Extended Leave Bank, a
percentage of your salary will be covered for a certain amount of time if you become disabled due to
pregnancy or from a covered accidental bodily injury or illness which is not job-related.
Once your voluntary STD begins, benefit payments may be reduced by other income you receive or are eligible
to receive due to your disability, such as:
 any salary or wage continuation plan (including sick leave pay, paid time off, and/or extended leave bank
pay) of the employer
 federal, state and/or local disability income programs, including Social Security disability benefits
 disability Insurance
 unemployment benefits
 settlements or judgments for income loss
 any retirement benefits for which your employer fully or partially pays.
Your benefit payments will not be impacted by other income you receive, such as:
 retirement benefits you were already receiving before you became disabled
 retirement benefits you start to receive that are funded by your after-tax contributions
 your personal savings, investments, IRAs, or similar savings accounts
 profit-sharing
 personal disability policies
 Social Security increases.
Your coverage for the calendar year is determined by your Basic Annual Earnings. When you first enroll for
coverage, your Basic Annual Earnings is determined as of your date of hire. Each January 1, your coverage is
adjusted to reflect your Basic Annual Earnings as of the previous October 1.
Basic Annual Earnings does not include:
 bonuses,
 settlement pay,
 overtime pay, or

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 Short-Term Disability

 any other additional pay, income or fringe benefits.

Total Disability or Totally Disabled means that you are prevented from performing the essential duties of your
occupation and, as a result, you are earning less than 20% of your pre-disability earnings.
Disabled and Working means that you are prevented from performing some, but not all, of the essential duties
of your occupation by injury, sickness, mental illness, substance abuse, or pregnancy and are working on a
part-time or limited-duty basis, and as a result, your current weekly earnings are more than 20%, but less than
or equal to 80%, of your pre-disability earnings.

GENERAL PLAN PROVISIONS

The following describes general provisions of the Plan.

BENEFIT WAITING PERIOD

Once you are approved for benefits, you will be eligible to collect Short-Term Disability benefits starting on the
8th calendar day after the date of your disability, unless you have an accrued extended leave bank.

NO WAIVER OF PREMIUM
Premiums must continue to be paid during an approved period of STD.

RECURRENT DISABILITY
Separate periods of Disability resulting from the same or related causes will be considered one period of
Disability unless separated by your return to Active Service for at least 15 consecutive days if you elected the
12-week Plan, or at least 30 consecutive days if you elected the 25-week Plan.

REHABILITATIVE EMPLOYMENT
If you are receiving STD benefits and begin working as part of a program of Rehabilitative Employment, the
Plan will continue to pay your weekly benefit for the maximum payment period otherwise allowed, minus 50%
of any income you receive from Rehabilitative Employment. If the sum of your STD benefit and Rehabilitative
Employment income exceeds 100% of your pre-disability earnings, your STD benefit will be reduced so that
the total does not exceed 100%.

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 Short-Term Disability

WHEN BENEFITS END

Benefits will end on the first to occur of:
 the date you are no longer disabled
 the date you fail to furnish proof of your disability
 the date you are no longer under the regular care of a physician or you refuse to be examined by a
physician or other qualified medical professional
 the date of your death
 the date any limitation on the duration of benefits, as stated in the policy, is reached
 the date your current weekly earnings is 80% of your pre-disability earnings, as defined in the policy
 the date you refuse to receive appropriate and available treatment that is generally acknowledged by
physicians to cure, correct, or limit the disabling condition.

WHAT’S NOT COVERED

Benefits are not payable for disabilities caused or contributed to by:
 an act of a declared or undeclared war
 intentionally self-inflicted injury
 your commission of, or attempt to commit, a felony
 your being engaged in an illegal occupation
 sickness or injury for which Workers’ Compensation benefits are paid, or may be paid, if duly claimed
 injury sustained as a result of doing any work for pay or profit for another employer.
You must be under the regular care of a physician to receive benefits.

CLAIMS

FILING A CLAIM
Call Hartford's toll-free number to report your STD claim information: (855) 764-9234 Monday through Friday,
from 8:00 a.m. to 8:00 p.m. Eastern Time.

IF A CLAIM IS DENIED
If a claim is denied, in whole or in part, you will be notified writing. The notice will:
 state the specific reason for the denial
 refer to the applicable section of the policy

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 Short-Term Disability

 describe additional information necessary to reprocess the claim

 provide an explanation of the review procedure.
For additional information, refer to “Non-Health Claim Filing and Appeal Procedures” on page 176 in the “Plan
Administration Information” section of this SPD.

FILING AN APPEAL
You may file an appeal on any claim. To do so:
 Request a review with a written application if your claim is within:
 180 days of receipt of the claim denial if the claim requires a disability determination, or
 60 days of receipt of the claim denial if there is no disability determination.
 Request copies of all documents, records and information relevant to your claim.
 Submit written comments, records and documents relating to your claim.
You will receive a response within 45 days of a timely appeal. Refer to the policy for complete claim denial and
appeals information.

WHEN COVERAGE ENDS

Your coverage will end on the earliest of the following:
 the last day of the pay period in which you make required premium contributions
 the last day of the pay period in which you are no longer eligible for coverage, through either a change in
eligible employment or termination of employment
 The date that your coverage is terminated by amendment of the Plan, by whole or partial termination of
the Plan, by termination of the Master Policy, or by discontinuance of contributions by UHS.
Should the Plan be discontinued for any reason, benefits on an established claim would continue as though
the Plan had remained in force.

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 Long-Term Disability
Long-Term Disability (LTD) coverage through The Hartford Life and Accident
Insurance Company helps ensure income when you are ill or injured and are not
able to work for an extended period of time. It covers disability sustained on or off
the job that lasts longer than 90 or 180 calendar days.

In this Section
Long-Term Disability at a Glance ................................................................................................................................................... 128
Eligibility........................................................................................................................................................................................ 128
Enrollment .................................................................................................................................................................................... 128
Actively at Work Provision .............................................................................................................................................................. 128
Cost of Coverage ........................................................................................................................................................................... 129
How LTD Works ............................................................................................................................................................................. 129
LTD Plan 180 ................................................................................................................................................................................... 130
LTD Plan 90 ..................................................................................................................................................................................... 130
Definition of Disability ................................................................................................................................................................... 131
Recurrent Periods of Disability ....................................................................................................................................................... 131
How Benefits Are Paid ................................................................................................................................................................... 131
Benefit Offsets by Other Sources of Income .................................................................................................................................. 131
Lump Sum Payments ...................................................................................................................................................................... 132
Benefit Calculation Beyond 12 Months of Benefits ........................................................................................................................ 132
Survivor Benefit .............................................................................................................................................................................. 132
General Plan Provisions ................................................................................................................................................................. 132
Return to Work Incentive ............................................................................................................................................................... 132
Rehabilitation Benefit ..................................................................................................................................................................... 133
Family Care Credit ........................................................................................................................................................................... 133
When Benefits End ......................................................................................................................................................................... 133
Pre-Existing Conditions ................................................................................................................................................................... 134
Continuity of Coverage and Pre-Existing Condition Limitation....................................................................................................... 134
Waiver of Premium ......................................................................................................................................................................... 134
Mental Illness, Alcoholism, and Substance Abuse Limitation......................................................................................................... 134
What's Not Included ...................................................................................................................................................................... 135
Claims............................................................................................................................................................................................ 135
Filing a Claim ................................................................................................................................................................................... 135
If a Claim Is Denied ......................................................................................................................................................................... 135
Filing an Appeal............................................................................................................................................................................... 136
When Coverage Ends ..................................................................................................................................................................... 136

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 Long-Term Disability

LONG-TERM DISABILITY AT A GLANCE

You can select either the Plan 180 or Plan 90.
Plan 180 Benefits begin after 180 calendar days of continuous disability
Plan 90 Benefits begin after 90 calendar days of continuous disability

 With Plan 180, your period of disability will be considered continuous even if you temporarily return to
work for up to 90 calendar days during the benefit waiting period. If you return to work, the benefit
waiting period will extend by the number of days you temporarily return to work. The benefit waiting
period is also called the elimination period. This period will include the expiration of any Short-Term
Disability benefits or a salary continuation program.
 With Plan 90, your period of disability will be considered continuous even if you temporarily return to
work for up to 45 calendar days during the benefit waiting period. The benefit waiting period will be
extended by the number of days you temporarily returned to work.
If you decline LTD coverage, your income will end after you have exhausted any Extended Leave Bank (ELB) or
Paid Time Off (PTO) you may have accumulated.

ELIGIBILITY
You are eligible to enroll 30 days following the date you begin employment or change to a benefit eligible
status, provided you are regularly scheduled to work a minimum of 30 hours per week and you are not
covered by a collective bargaining agreement, unless the agreement provides for such coverage. Eligibility for
employees scheduled to work less than 30 hours per week may vary by UHS location.
Check with your Human Resources Department to confirm your eligibility. You must enroll to be covered by
any benefit plan.

ENROLLMENT
You are eligible to enroll during the annual enrollment period each year. If you are a new employee you will
have 30 calendar days to enroll. If you are a newly eligible employee, you may enroll for coverage 30 calendar
days after your status change.

ACTIVELY AT WORK PROVISION

If you are absent from work due to accident or illness on the date your insurance would become effective, or a
change is due to be effective, the coverage or change will not become effective until you are Actively at Work
one full day.

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 Long-Term Disability

COST OF COVERAGE
Your contributions are post-tax through payroll deductions. The cost of coverage is based upon your age and
the level of coverage you elect. For more information, refer to the "2024 UHS All BENEFITS - All Locations -
Cost Sheet" available in your enrollment materials or by contacting your Human Resources Department.

HOW LTD WORKS

If you become disabled from a covered accidental bodily injury, illness, or pregnancy, the LTD Plan will pay you
an income equivalent up to 60% of your Basic Annual Earnings when combined with all other benefits which
you and your dependents may receive, to a maximum benefit of $10,000 per month and a minimum of $50
per month.
To qualify for benefits, you must be disabled and not be receiving pay for work performed at more than 80%
of your pre-disability earnings during the waiting period.
Your coverage for the calendar year is determined by your Basic Annual Earnings. When you first enroll for
coverage, your Basic Annual Earnings is determined as of your date of hire. Each January 1, your coverage is
adjusted to reflect your Basic Annual Earnings as of the previous October 1.
Basic Annual Earnings does not include:
 bonuses,
 settlement pay,
 overtime pay, or
 any other additional pay, income or fringe benefits.
If you are not in active service on that day, no increase in Basic Annual Earnings will be considered effective if
it occurs:
 between separate periods of Disability which are considered one period under the successive periods of
disability provision, or
 during a benefit waiting period.
Within these periods, the income is payable up to two years for a disability that prevents you from performing
the material and substantial duties of your own occupation. Your own occupation includes jobs in the national
economy, not the specific job you were performing for a specific employer.

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 Long-Term Disability

LTD PLAN 180

A benefit period begins on the 181st consecutive calendar day of disability and can continue, depending on
your age at commencement of disability, as outlined below:
Age When Disability Begins Benefits Payable
Age 62 or Younger To Normal Retirement Age1 or 42 months, if greater

Age 63 To Normal Retirement Age1 or 36 months, if greater

Age 64 30 months

Age 65 24 months

Age 66 21 months

Age 67 18 months

Age 68 15 months

Age 69 and Older 12 months

1 Normal Retirement Age means the Social Security Normal Retirement Age as stated in the 1983 revision of the United States Social Security
Act.

LTD PLAN 90
A benefit period begins on the 91st consecutive calendar day of disability and can continue, depending on
your age at commencement of disability, as outlined below:
Age When Disability Begins Benefits Payable:

Age 62 or Younger To Normal Retirement Age1 or 48 months, if greater

Age 63 To Normal Retirement Age1 or 42 months, if greater

Age 64 36 months

Age 65 30 months

Age 66 27 months

Age 67 24 months

Age 68 21 months

Age 69 and Older 18 months

1 Normal Retirement Age means the Social Security Normal Retirement Age as stated in the 1983 revision of the United States Social Security
Act.

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 Long-Term Disability

DEFINITION OF DISABILITY
A determination of disability is made using an “essential duties test.” This means that the disability prevents
you from performing a duty which is substantial, fundamental, or inherent to your occupation and cannot be
reasonably omitted. In addition, the essential duties test also includes your ability to work a number of hours
in a regularly scheduled work week. Even if you can perform all the duties of your occupation, but only on a
part-time (or reduced hours) basis, or are being paid for work performed at no more than 80% of your pre-
disability earnings, you would be considered disabled.
Payments continue beyond two years if you are unable to perform the essential duties of any occupation for
which you are, or could reasonably become, qualified by reason of your education, training, or experience.
With respect to all active Corporate and Division Officers of Universal Health Services, Inc., disability means
unable to perform all the essential duties of your own occupation.
While you are disabled, you must be under the care of a duly qualified physician other than yourself.

RECURRENT PERIODS OF DISABILITY

Separate periods of disability resulting from the same or related causes will be considered one period of
disability unless separated by your return to active service for at least 6 consecutive months.
Separate periods of disability resulting from unrelated causes will be considered one period of disability unless
separated by your return to active service for at least one full day.
These provisions do not apply to the benefit waiting period.

HOW BENEFITS ARE PAID

Your LTD Plan coverage determines when benefits are paid under the Plan.

BENEFIT OFFSETS BY OTHER SOURCES OF INCOME

The insurance company reserves the right to reduce your monthly benefit by estimating the Social Security
benefits that you or your dependents may be eligible to receive.
Other Income Benefits include, but are not limited to, any amounts for which you may also be eligible under:
 any group or franchise insurance or similar plan for persons in a group
 any local, state, provincial, or federal government disability or retirement plan or law
 any salary or wage continuation plan of the employer
 the Jones Act; or any Workers' Compensation, Occupational Disease or similar law including all permanent
as well as temporary disability benefits
 any work loss provision in the mandatory part of any "No Fault" auto insurance policy

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 Long-Term Disability

 any benefit which you receive for (or are assumed to receive) under the Federal Social Security Act on your
own behalf, or any benefit which you receive (or are assumed to receive) on behalf of your dependents, or
which your dependents receive on account of your receipt or assumed receipt under the Federal Social
Security Act
 the Canada-Quebec Pension Plans
 any retirement benefits which you receive under a retirement plan sponsored by the Employer, except IRC
Section 401(k) plans.

LUMP SUM PAYMENTS

If you are paid other benefits in a lump sum, the Plan will pro-rate the lump sum over the period of time it
would have been paid if not paid in a lump sum. If such period cannot be determined, the Plan will pro-rate
the lump sum over a period of 24 months.

BENEFIT CALCULATION BEYOND 12 MONTHS OF BENEFITS

After this 12-month period, your monthly benefit is calculated as follows:
 your monthly income loss is multiplied by 60%
 from the lesser of this figure or $10,000, certain other benefits you or your family receive as the result of
your disability or retirement are deducted.

SURVIVOR BENEFIT
If you die after you have been receiving benefits from the Plan, your eligible survivor (i.e., your spouse or
children) will receive a lump sum benefit. The benefit is one lump sum payment equal to six times the
lesser of:
 your monthly income loss multiplied by the benefit percentage; or
 $10,000.

GENERAL PLAN PROVISIONS

The following describes general provisions of the Plan.

RETURN TO WORK INCENTIVE

If you work while disabled, the insurance company may allow up to 100% income replacement for up to 12
consecutive months, beginning with the first date you start such work, or the end of the elimination period.
Current monthly earnings are not used to reduce your benefit unless the sum of your monthly benefit and
current earnings exceeds 100% of your pre-disability earnings.

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 Long-Term Disability

REHABILITATION BENEFIT
Rehabilitation is a process of working together to plan, adapt, and put into use, options and services to meet
your return-to-work needs.
A rehabilitation program may include, but is not limited to, vocational testing and training, alternative
treatment plans, workplace modifications where possible, and job placement.

FAMILY CARE CREDIT

If you are working as part of a program of rehabilitative employment, the insurance company will, for the
purpose of calculating your benefit, deduct the cost of family care from earnings received from a rehabilitative
program. The monthly maximum deduction allowed is $350 for the first 12 months of participation and $175
per month thereafter. The maximum credit allowed in a year is $2,500 with a maximum period of 24 months.
This provision provides a deduction/credit for care provided by a caregiver that is not a family member. A
receipt must support the payment.
Credit may be given for the care of a child under age 13 or a member of your household who is mentally or
physically handicapped and dependent on you for support.

WHEN BENEFITS END

Benefits will end on the first to occur of:
 the date you are no longer disabled
 the date you fail to furnish proof, when requested by the insurance company, that you continue to be
disabled
 the date you are no longer under the regular care of a physician or you refuse to be examined by a
physician, if the insurance company requires such an examination
 the date of your death
 the date any limitation on the duration of benefits as stated in the policy is reached
 the date any earnings you receive from any employer or for any work, while disabled or eligible for
benefits under this Plan, exceed 80% of your indexed pre-disability earnings as defined in the policy
 the date you refuse to receive appropriate and available treatment that is generally acknowledged by
physicians to cure, correct, or limit the disabling condition
 the date you refuse to participate in or cooperate with a rehabilitation program or refuse to try
recommendations under a rehabilitation program.

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 Long-Term Disability

PRE-EXISTING CONDITIONS
The Plan will not pay monthly benefits for any period of disability which results from an injury or sickness for
which you incurred expenses, received medical treatment, took prescribed drugs or medicines, or consulted a
physician during the 90 days before the most recent effective date of your insurance. This limitation will not
apply to a period of disability which begins more than 365 days after the most recent effective date of your
insurance or after the last day of 90 consecutive days during which you receive no medical care for the pre-
existing condition.

CONTINUITY OF COVERAGE AND PRE-EXISTING CONDITION LIMITATION

The pre-existing condition limitation will be waived if you were insured on the day before the effective date of
this policy under a group Long-Term Disability policy sponsored by your employer and replaced by this policy,
provided you are actively at work on the effective date of this policy and have fulfilled the requirements of any
pre-existing condition limitation of the replaced policy.
However, if you are actively at work on the effective date of this policy and have not fulfilled the requirements
of any pre-existing condition limitation of the replaced policy, no credit will be applied toward the satisfaction
of the time period requirement of the pre-existing condition limitation of this policy.
Benefits determined to be payable will be paid according to the provisions of this policy.

WAIVER OF PREMIUM
You will not need to pay any premium while monthly benefits are payable to you.

MENTAL ILLNESS, ALCOHOLISM, AND SUBSTANCE ABUSE LIMITATION

The Plan will pay monthly benefits up to 24 months per lifetime for disability caused or contributed to by
mental illness, alcoholism, or substance abuse while you are not confined in a hospital. If you are confined in a
hospital, benefits will be paid for the length of the hospitalization.
Mental illness means a mental disorder as listed in the current Diagnostic and Statistical Manual of Mental
Disorders, published by the American Psychiatric Association. A mental illness may be caused by biological
factors or result in physical symptoms or manifestations.
For the purpose of this Plan, mental illness does not include the following mental disorders outlined in the
Diagnostic and Statistical Manual of Mental Disorders:
 mental retardation
 pervasive developmental disorders
 motor skills disorder
 substance–related disorders

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 delirium, dementia, and amnesic and other cognitive disorders, or

 narcolepsy and sleep disorders related to a general medical condition.
Substance abuse means the pattern of pathological use of alcohol or other psychoactive drugs and substances
characterized by:
 impairments in social and/or occupational functioning,
 debilitating physical condition,
 inability to abstain from or reduce consumption of the substance, or
 the need for daily substance use to maintain adequate functioning.
Substance includes alcohol and drugs, but excludes tobacco and caffeine.

WHAT'S NOT INCLUDED

A benefit is not payable for any disability caused or contributed to by:
 an act of a declared or undeclared war,
 an intentionally self-inflicted injury,
 your commission of, or attempt to commit, a felony, or
 your being engaged in an illegal occupation.
You must be under the regular care of a physician to receive benefits.

CLAIMS
Use this information to file claims for benefits under the Plan.

FILING A CLAIM
Call Hartford’s toll-free number to report your LTD claim: (855) 764-9234 Monday through Friday, from
8:00 a.m. to 8:00 p.m. Eastern Time.

IF A CLAIM IS DENIED
If a claim is denied, in whole or in part, you will be notified in writing. The notice will:
 state the specific reason for the denial
 refer to the applicable section of the policy
 describe additional information necessary to reprocess the claim
 provide an explanation of the review procedure.

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For additional information, refer to “Non-Health Claim Filing and Appeal Procedures” on page 176 in the “Plan
Administration Information” section of this SPD.

FILING AN APPEAL
You may file an appeal on any claim. To do so:
 Request a review with a written application if within:
 180 days of receipt of the claim denial if the claim requires a disability determination, or
 60 days of receipt of the claim denial if there is no disability determination.
 Request copies all documents, records and information relevant to your claim.
 Submit written comments, records and documents relating to your claim.
You will receive a response within 45 days of a timely appeal. Refer to the policy for complete claim denial and
appeals information.

WHEN COVERAGE ENDS

Your coverage will end on the earliest of the following:
 the last day of the pay period in which you make required premium contributions
 the last day on which premiums are paid
 the last day of the pay period in which you are no longer eligible for coverage, through either a change in
eligible employment or termination of employment
 The date that your coverage is terminated by amendment of the Plan, by whole or partial termination of
the Plan, by termination of the Master Policy, or by discontinuance of contributions by UHS.
Should the Plan be discontinued for any reason, payments on an established claim would continue as though
the Plan had remained in force.

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The Universal Health Services, Inc. Retirement Savings Plan (the 401(k) Plan or the
Plan), is designed to help you build long-term savings to supplement your
retirement income. The Plan helps you take charge of your financial future by
offering a convenient way to save and invest through a combination of your
contributions and Company matching contributions, which you can invest among
various investment options offered through Fidelity Management Trust Company
(Fidelity), the Plan’s trustee and recordkeeper. You can contact Fidelity by visiting
www.401k.com or calling Fidelity Customer Service at (800) 835-5092.

For More Information

For information about your legal rights under ERISA and other important administrative details, see “Plan
Administration Information” on page 162. The Plan Administration Information section, along with the 401(k)
Plan benefit information included here, form an ERISA Summary Plan Description (SPD) for the 401(k) Plan. To
contact the Plan Administrator, see Plan Administration Information or visit Fidelity’s website at
www.401k.com.

In this Section
How the Plan Works ...................................................................................................................................................................... 139
Eligibility........................................................................................................................................................................................ 139
Participation and Enrollment .......................................................................................................................................................... 140
Participation from a Prior Plan ....................................................................................................................................................... 140
Your Beneficiary .............................................................................................................................................................................. 140
About Your Contributions.............................................................................................................................................................. 141
Definition of Compensation ............................................................................................................................................................ 141
Contribution Limits ......................................................................................................................................................................... 141
Special Rights Upon Return from Military Service .......................................................................................................................... 141
Your Plan Contributions ................................................................................................................................................................ 142
Limits for Highly Compensated Employees .................................................................................................................................... 142
Changing Your Contributions .......................................................................................................................................................... 142
Pre-Tax Contributions ..................................................................................................................................................................... 143
Roth After-Tax Contributions .......................................................................................................................................................... 143
Rollover Contributions .................................................................................................................................................................... 143
Qualified Non-Elective Contributions ............................................................................................................................................ 144
Company Matching Contributions ................................................................................................................................................. 144

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Vesting in Company Matching Contributions ................................................................................................................................. 145

Forfeitures ...................................................................................................................................................................................... 145
Your Investment Choices ............................................................................................................................................................... 146
Default Investment Option ............................................................................................................................................................. 146
Investment Earnings, Losses and Gains .......................................................................................................................................... 147
Changing Your Investment Elections .............................................................................................................................................. 147
Compliance with Section 404(c) of ERISA ....................................................................................................................................... 147
Account Statement ......................................................................................................................................................................... 148
Accessing Your Assets While Employed ......................................................................................................................................... 148
Loans for Active Employees ............................................................................................................................................................ 148
If You Leave UHS with an Outstanding Loan................................................................................................................................... 149
Age 59½ In-Service Distributions .................................................................................................................................................... 149
Active Military Duty Withdrawals ................................................................................................................................................... 149
Hardship Withdrawal ...................................................................................................................................................................... 150
Early Withdrawal Tax Penalty ......................................................................................................................................................... 150
Withdrawals from Rollover and Prior Plan Subaccounts ................................................................................................................ 151
Distributions When You Leave the Company................................................................................................................................. 151
Payment of Prior Plan Subaccounts ................................................................................................................................................ 152
If You Retire .................................................................................................................................................................................... 152
When You Die ................................................................................................................................................................................. 153
When You Reach Age 72 ................................................................................................................................................................. 153
If Your Account Balance Is Less Than $7,000 .................................................................................................................................. 153
Taxes on Your Distribution.............................................................................................................................................................. 154
Understanding Your 401(k) Plan Participation ............................................................................................................................... 154
If You Leave UHS and Are Rehired .................................................................................................................................................. 154
Credited Service .............................................................................................................................................................................. 155
Break in Service............................................................................................................................................................................... 155
Leaves of Absence and Layoff ......................................................................................................................................................... 156
Plan Administration Information ................................................................................................................................................... 156
Non-Assignment of Benefits .......................................................................................................................................................... 159
Plan Termination Insurance ............................................................................................................................................................ 159
Future of the Plan.......................................................................................................................................................................... 159
Top Heavy Provisions .................................................................................................................................................................... 159
Qualified Domestic Relations Order .............................................................................................................................................. 159
Claims............................................................................................................................................................................................ 160
Filing a Claim ................................................................................................................................................................................... 160
If Your Claim Is Denied .................................................................................................................................................................... 160
Litigation after Final Appeal ............................................................................................................................................................ 160
Appendix A – Participation from a Prior Plan ................................................................................................................................ 161

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HOW THE PLAN WORKS

The 401(k) Plan makes it easy to save for your retirement. The Plan offers several savings advantages,
including:
 Convenient Payroll Deductions: You may contribute from 1% to 75% of your eligible compensation each
year, up to applicable IRS limits. You can make pre-tax or Roth after-tax contributions to your account
through payroll deductions. Your combined pre-tax and Roth after-tax contributions cannot exceed the IRS
maximum annual deferral amount.
 Tax Deferrals: You do not pay taxes on regular, pre-tax contributions or any earnings on your account until
distribution. Although Roth contributions are made on an after-tax basis, if you meet the requirements for
a qualified Roth distribution (which includes leaving your Roth contributions in the 401(k) Plan for at least
five years) you will not be taxed on earnings on your Roth contributions.
 Investment Choices: The Plan offers you a broad selection of professionally managed investment funds for
your savings and an opportunity to change your investments on a daily basis (subject to certain investment
restrictions).
 Access to Your Money: You may borrow or withdraw money from your 401(k) account before retirement
(subject to certain requirements).
 Vesting: You are always 100% vested in your pre-tax, Roth after-tax and rollover contributions. Your
employer contributions become vested at a rate of 25% for each calendar year you work 1000 or more
hours. You become 100% vested after completing four years of eligible service.
 Distribution of Your Account: When you retire, the full value of your vested account is available to you.

ELIGIBILITY
If you are regularly scheduled to work at least 20 hours per week and your wages are reported on Form W-2,
you are eligible to participate in the Plan as of the first payroll period following the date you reach age 21 and
complete 30 days of credited service. In general, you earn one day of credited service after you complete one
shift or one day of schedule work in which you are paid or entitled to pay from UHS. See “Credited Service” on
page 155 for more information.
If you are not regularly scheduled to work 20 hours per week, or you are per diem and worked at least 500
hours during the prior three consecutive years, you may be considered a long-term part-time employee under
the SECURE Act and eligible to participate in the 401(k) Plan. If you are eligible, Fidelity will send you an
enrollment book. Contact Fidelity Customer Service at (800) 835-5092 for more information.
You are not eligible to participate in the Plan if:
 you are covered by a collective bargaining agreement, unless the agreement specifically provides for such
coverage,
 you are a per diem or temporary employee and are not regularly scheduled to work 20 hours per week or
have not worked at least 500 hours during the prior three consecutive years, or

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 you change to a per diem or temporary status and are not regularly scheduled to work 20 hours per week
or have not worked at least 500 hours during the prior three consecutive years.

PARTICIPATION AND ENROLLMENT

Your participation in the Plan begins as early as the payroll period following the date you become eligible and
after you complete your 401(k) Plan enrollment through Fidelity. As an eligible employee, you may enroll in
the Plan at any time, online at www.401k.com. You may also enroll by calling Fidelity Customer Service at
(800) 835-5092.
When you enroll, you will:
 indicate the percentage of your eligible compensation you want to contribute to the Plan on pre-tax or
Roth after-tax basis, if eligible,
 select the funds into which your contributions will be invested, and
 designate your beneficiaries.
By completing your enrollment, you are authorizing UHS to reduce your compensation by the amount of your
pre-tax and/or Roth after-tax contributions. Payroll deductions begin as soon as administratively possible
following the processing of your enrollment.

PARTICIPATION FROM A PRIOR PLAN

If you had a pension benefit or account balance under another employer-sponsored retirement plan which
was transferred or merged into the 401(k) Plan, you may have a separate “subaccount” with the 401(k) Plan.
The subaccount contains the balances related to your prior account, such as annuity payments, in-service
distributions, or loans. All prior plan provisions and restrictions, such as the available forms of payment and
vesting schedule, remain attached to this subaccount. See “Appendix A – Participation from a Prior Plan” on
page 161 for a complete list of plans than merged with or transferred into the 401(k) Plan.

YOUR BENEFICIARY
You must name a beneficiary, beneficiaries, or a trust to receive your Plan account balances if you die. If you
are married and wish to name a beneficiary other than your spouse, you must complete the Beneficiary
Designation Form, available from Fidelity, and have it notarized with your spouse's written consent, agreeing
to another beneficiary. Please review your beneficiary designation periodically and update it if your marital
status changes.
You may designate beneficiaries online at www.401k.com or by calling Fidelity at (800) 835-5092.

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ABOUT YOUR CONTRIBUTIONS

The Internal Revenue Service (IRS) and the Plan place certain restrictions on your Plan contributions.

DEFINITION OF COMPENSATION
Your eligible compensation for Plan deferral purposes means your annual earnings, including bonuses, and
overtime pay. Fringe benefits, severance pay, wages received as the result of equity compensation paid by the
Company, and wages received under California’s Hospital and Skilled Nursing Facility COVID-19 Worker
Retention Payments act are not included in your compensation for Plan purposes.
If your compensation changes, the amount deducted from your paycheck and contributed to the Plan is
automatically adjusted to reflect that change. Any increase in your contributions will be allocated among the
Plan’s funds in the proportion you elect.

CONTRIBUTION LIMITS
The IRS limits the amount of contributions that can be made to the 401(k) Plan each year. In addition to an
annual dollar limit on your contributions, the IRS places a number of additional limits on the amount that you
and UHS may contribute in any one year to the Plan. These limits may be adjusted from time to time.
Annual Limits Plan Year 2024
Maximum Participant Contributions $23,000
The maximum amount that you can contribute to the Plan in pre-tax and Roth after-tax contributions
Maximum Participant Contributions – Including Catch-up1 $30,500
The maximum amount that you can contribute, including catch-up contributions, if eligible
Maximum Total Contributions (Participant and Employer) $69,000
The maximum amount that can be contributed to your 401(k) Plan account in pre-tax contributions, Roth
after-tax contributions, and Company matching contributions. Note: Catch-up contributions are not
included in this limit.
Annual Limit on Recognized Compensation $345,000
The maximum amount of your compensation that will be considered by the Plan
1 If you will be age 50 or older during the Plan Year, the combined IRS contribution limit for both pre-tax and Roth after-tax contributions will
increase to allow for additional contributions as “catch-up” contributions.

Typically, if your contributions to the Plan reach any of these limits during the year, your contributions will be
stopped. Your contribution elections will automatically resume at the beginning of the following year.

SPECIAL RIGHTS UPON RETURN FROM MILITARY SERVICE

If you return to work after a qualifying military leave, you can "make up" the contributions that you could have
made if you had not gone on military leave. Your right to "make up" contributions lasts for a specific period. By
law, that period is three times your military leave, up to a maximum make-up period of five years. For

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example, if you had been on active duty for 12 months, you would have the right to make up any missed
contributions for three years following your return. If you had been on active duty for 24 months, you would
have the right to make up any missed contributions for five years (the maximum period) following your return.
For information about a qualifying military leave, see “Leaves of Absence and Layoff” on page 156.

YOUR PLAN CONTRIBUTIONS

There are three ways you can contribute to the Plan:
 pre-tax contributions,
 Roth after-tax contributions, and
 rollover contributions from a previous plan.
You can contribute from 1% to 75% of your eligible compensation, to the Plan, subject to annual IRS limits.
When electing your deferral percentage, keep your other payroll deductions in mind as the payroll system will
either deduct the full amount of your deferral percentage election, or nothing at all depending on whether
your paycheck can support full amount of your deferral percentage election.

LIMITS FOR HIGHLY COMPENSATED EMPLOYEES

Federal rules require that plans which provide pre-tax, Roth after-tax and employer matching contributions do
not disproportionately benefit highly compensated employees (HCEs). You are generally considered a HCE for
2024 if you earned $150,000 or more in 2023. This limit is periodically adjusted for increases in the cost of
living.
In addition, the Plan has to satisfy certain nondiscrimination requirements under federal law designed to
evaluate whether the amount of pre-tax and/or Roth after-tax contributions are spread fairly among all
eligible employees. To satisfy these requirements, it may be necessary at times to limit the amount higher
compensated employees can contribute to the Plan.
If you are an HCE, you can defer up to 11% of your eligible compensation (on a pre-tax, Roth after-tax, or a
combination of both) or up to the IRS annual contribution limits. You will be notified of any limitation in your
contributions. If any contributions are required to be returned to you, they will be adjusted for earnings and
losses.

CHANGING YOUR CONTRIBUTIONS

You may change, stop or resume your contributions at any time by calling Fidelity Customer Service at (800)
835-5092 or visiting www.401k.com. Your request to change the amount or stop your contributions will be
effective as soon as administratively practicable following the date you submit your request.

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You also can have your contribution percentage automatically increased by a set amount each year, by
enrolling in Fidelity's Annual Increase Program. For more information on the Annual Increase Program, contact
Fidelity Customer Service or visit www.401k.com.

PRE-TAX CONTRIBUTIONS
Pre-tax contributions are deducted from your paycheck before federal and most state and local income taxes
are withheld, thereby reducing your current taxable income and deferring the taxes you will owe on these
contributions until you take a distribution from the Plan. Pre-tax contributions are, however, subject to Social
Security and Medicare taxes, which means that contributing to the Plan will not reduce your Social Security
benefits.
The investment earnings on your pre-tax contributions are not subject to federal income taxes until you take a
distribution from the Plan.
When you receive your account balance from the Plan, all contributions and investment earnings will be
taxable.

ROTH AFTER-TAX CONTRIBUTIONS

Unlike pre-tax contributions, Roth after-tax contributions are deducted from your paycheck after federal, state
and local income taxes are withheld (including Social Security and Medicare taxes).
The investment earnings on your Roth after-tax contributions grow tax-free, provided you satisfy two
requirements before you withdraw them:
 At least five years have passed since you made your first Roth after-tax contribution to the Plan
 You must not withdraw the contributions until you are at least 59½ years old.
 This second requirement is waived if you are disabled.
If you die before age 59½, your beneficiary will receive the benefit of tax-free earnings on these contributions.
The tax rules governing Roth after-tax contributions are complicated. You may want to consult your tax
advisor regarding the financial impact of making Roth after-tax contributions, and how they might fit into your
retirement income planning.

ROLLOVER CONTRIBUTIONS
You may roll over all or part of an "eligible rollover distribution" from a prior employer's qualified retirement
plan into your 401(k) Plan account. The Plan currently accepts rollover contributions from:
 401(a) qualified plans (including 401(k) plans)
 403(a) qualified annuities
 403(b) tax sheltered annuity plans

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 457(b) state and local government deferred compensation plans

 conduit IRAs (i.e., rollover IRA)
 non-conduit IRAs, such as traditional IRAs and Simplified Employee Pension plans, but not Roth IRAs
 Roth 401(a) and Roth 401(k) plans.
If the rollover is not a direct rollover (i.e., if you received a cash distribution from a prior employer's qualified
plan or from your rollover IRA), then it must be received by Fidelity within 60 days of your receipt of the
distribution. Rollover contributions are subject to the terms of the Plan but are always fully vested and non-
forfeitable.
Rollovers must follow the administrative procedures set forth by Fidelity. Call Fidelity Customer Service at
(800) 835-5092 for more information and applicable rollover forms.
Your rollover contributions will be subject to the terms of this Plan and will always be fully vested and non-
forfeitable.

QUALIFIED NON-ELECTIVE CONTRIBUTIONS

You may receive a Qualified Non-Elective Contribution (QNEC) in order for the Plan to meet certain regulatory
requirements imposed by the IRS and Department of Labor. For instance, if the Plan fails certain
nondiscrimination tests, UHS may, in its sole discretion, make additional contributions to the Plan that would
cause the Plan to pass such tests. These contributions are 100% vested at the time of deposit, and are subject
to the Plan’s standard rules and regulations around withdrawals.

COMPANY MATCHING CONTRIBUTIONS

The Company matches certain employee contributions, up to a limit, based on the amount you contribute.
Company matching contributions are accrued each pay period based on your own match-eligible
contributions, and will be deposited into your account every pay period. Contact your local Human Resources
Department for information on the amount of your Company matching contribution. You may also log into
your Fidelity account to view the formula.
Company matching contributions are initially invested in the same funds you have chosen to invest your
personal contributions.
You pay no taxes on the Company matching contributions at the time they’re credited to your account or on
the investment earnings on those contributions. These amounts will be subject to income taxes when you take
a distribution from the Plan.
If you participate in the 401(k) Plan as a long-term part-time employee, you are not eligible for Company
matching contributions. If your employment status changes and you are regularly scheduled to work at least
20 hours per week and your wages are reported on Form W-2, you may be eligible for Company matching
contributions. Contact Fidelity Customer Service at (800) 835-5092 for more information.

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VESTING IN COMPANY MATCHING CONTRIBUTIONS

Vesting refers to your ownership in the Company matching contributions. You are always 100% vested in any
pre-tax, Roth after-tax, and rollover contributions that you make to the Plan.
Here’s how you become vested in your Company matching contributions:
Years of Credited Service Vested Percentage
Less Than 1 0%
1 But Less Than 2 25%
2 But Less Than 3 50%
3 But Less Than 4 75%
4 or More 100%

You will receive one year of credited service for each calendar year in which you work 1,000 hours, unless
otherwise specified in “Credited Service” on page 155. You do not have to work the entire calendar year as
long as you satisfy the 1,000 hours of service requirement.
You immediately become 100% vested in Company matching contributions if you are working for UHS when
you reach age 65, become totally disabled, or die.
If you leave UHS before you’re fully vested, you’ll lose (forfeit) the non-vested part of your Company matching
contributions along with their investment earnings. For more information on vesting under the Plan, log on to
your account at www.401k.com, or contact Fidelity at (800) 835-5092.
If you terminate your employment with UHS, the vesting schedule in place at the time of your termination will
apply to your account. If you had a pension benefit or account balance under another employer-sponsored
retirement plan which was transferred or merged into the Plan, your vesting service under your prior plan may
count toward your years of credited service. For more information about vesting service under prior plan
subaccounts, contact Fidelity Customer Service at (800) 835-5092.

FORFEITURES
If you end employment with UHS but are not 100% vested, you will forfeit the non-vested portion of your
account after five consecutive one-year breaks-in-service or if you take a distribution from the Plan, if earlier.
Forfeited amounts are used to offset future Company matching contributions to the Plan. If you have not
received a distribution of your vested account after termination of employment and are rehired before you
have five consecutive one-year breaks-in-service, you may be entitled to any non-vested forfeited amounts.

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YOUR INVESTMENT CHOICES

As a participant in the Plan, you can determine not only how much to save, but also how that money is
invested. Investment earnings play an important role in building your retirement savings. All contributions
made to your account will be credited with investment gains and losses based on the performance of the
investment funds you select.
The Plan provides a number of investment options you can use to invest your contributions, ranging from
conservative to more aggressive. You can select a mix of investment options that best suit your goals, time
horizon, and risk tolerance. As a Plan participant, you are responsible for deciding how to invest both your
current balance and future contributions. If you do not make an investment election, your contributions will
be directed to the Plan’s default fund, the FIAM Index Target Date Commingled Pool Class Y fund closest to the
year in which you turn 65. See “Default Investment Option” on page 146 for more information.
You have control over and responsibility for your investment choices. All investments involve some risk. The
value of your account can go up — or down — depending on several factors, such as changes in interest rates,
the level of inflation, fluctuations in the stock market and your investment decisions. The value of your
account will ultimately be determined by the investment results of the funds in which your account has been
invested.
You should consult your financial advisor to determine the level of risk and return that best suits your
investment needs and goals. For more information on individual investing and diversification, you can visit the
Investing and Diversification section on the Department of Labor’s website at
https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/pension-protection-act/investing-and-
diversification.
The full list of investment options for the Plan may be found by visiting www.401k.com. Here, you can see
prospectuses, fund performance, and other research materials.
The Company (including its employees, officers or agent) makes absolutely no guarantees or assurances
regarding the performance of the investment funds and will make no recommendation regarding your
investment decisions. You may visit www.401k.com or call Fidelity Customer Service at (800) 835-5092 for
further information regarding your account at any time.

DEFAULT INVESTMENT OPTION

If you do not make any investment elections for your contributions, undirected contributions will
automatically be deposited into a default investment fund designated by the Plan Administrator. The default
fund for the Plan is the FIAM Index Target Date Commingled Pool Class Y fund that most closely aligns with
your 65th birthday. Each target date fund is a diversified fund designed to become more conservative over
time.

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INVESTMENT EARNINGS, LOSSES AND GAINS

The value of your account balance is determined by the amount of your contributions, Company
contributions, amounts rolled over or transferred from another eligible retirement plan, and prior plan
accounts merged into the Plan, adjusted based on investment earnings and losses.
The amount of investment earnings credited to your account will depend on the investment fund or funds you
choose. Your account balance will be valued at the end of each business day on which the New York Stock
Exchange (NYSE) is open. This means that the trustee assesses the value of all contributions made to your
account, investment gains and losses, and withdrawals and loans from your account and assigns a value to
your total account every day the NYSE is open.

CHANGING YOUR INVESTMENT ELECTIONS

You can make two types of investment changes:
 Future contributions: You can change the way your future contributions are invested while maintaining
your existing account balances in the current investment mix. Your election will apply to your future
contributions. This is called an investment allocation change.
 Existing account balance(s): You can change the investment mix for your existing account balances in
either of two ways:
 You may transfer some or all of your existing account balances from a specific investment fund into
one or more specific replacement funds. This is called a fund-to-fund transfer; or
 You may rebalance your entire existing account balances by specifying the percentage you want in
each fund. This is called a reallocation.
You can make changes to your investments by logging on to your account at www.401k.com or calling Fidelity
Customer Service at (800) 835-5092.

COMPLIANCE WITH SECTION 404(C) OF ERISA

The Plan is intended to comply with section 404(c) of the Employee Retirement Income Security Act of 1974
(ERISA) and the related regulations issued by the U.S. Department of Labor. Those regulations generally
provide rules for plans that permit participants to direct the investment of their accounts. If those rules are
met, the Company, the Plan Administrator, the Trustee, and any other Plan fiduciaries are relieved of liability
for any losses that are the direct and necessary result of your investment instructions.

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ACCOUNT STATEMENT
You can log on to www.401k.com and run a statement for any time period (monthly, quarterly, etc.). The
online statement function and history feature allows you to go back for 10 years of history.
Alternatively, you can request that Fidelity send your statements by mail on a quarterly basis or sign up for
electronic statements. Your statement will list your account activity, including the amount of your
contributions, Company contributions, rollover contributions, investment gains and losses, prior plan
subaccount information, if applicable, the total current value of your account in each fund, and the total
current value of your entire account.

ACCESSING YOUR ASSETS WHILE EMPLOYED

Although the Plan is intended to provide income for retirement, you may need your money while you are still
working. However, in granting special tax advantages to programs like the 401(k) Plan, the federal government
limits how you may withdraw funds. This section explains when and how in-service withdrawal are available.
If you receive a distribution from the Plan before reaching age 59½, you will generally be subject to an
additional tax of 10%, unless you qualify for an exception. For more information on in-service distributions,
contact Fidelity. Please consult your tax advisor about the tax consequences of such a withdrawal.
Note: If you have a prior plan subaccount, certain other in-service distribution alternatives may be available
under the terms of your prior plan. Contact Fidelity Customer Service at (800) 835-5092 for information
regarding prior plan in-service distribution alternatives.

LOANS FOR ACTIVE EMPLOYEES

A loan allows you to borrow money from your account balances, and repay the loan with interest. You may
borrow from your own contributions, your rollover contributions, the vested portion of your Company
matching contribution, and the related investment earnings on any of these accounts. You do not pay current
taxes on the loan amount. Approved loans will normally be made within five business days following the day
of your request.
The following rules apply to 401(k) Plan loans:
 You may have only one outstanding loan from the Plan at a time.
 You may borrow up to 50% of your available vested account without restriction. However, to secure your
loan, the balance in your Plan account may never be less than your outstanding loan.
 Loans may not be more than the lesser of:
 $50,000, reduced by your largest outstanding loan balance during the 12-month period before the date
of the loan, or
 50% of your available vested account.

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 The minimum loan you may take is $750.

 You determine the repayment term of your loan.
 For most loans, the repayment term may not be longer than five years.
 If the loan is for the purchase of your principal residence, the loan may be repaid over up to 15 years.
 Loans are repaid on an after-tax basis in equal installments through automatic payroll deduction.
 You may pre-pay your loan in full at any time without penalty.
 The interest rate on your loan will be a competitive commercial rate selected by the Plan Administrator.
 If you are performing a qualified military service, you may be permitted to suspend loan payments for the
length of your military service, provided you return to employment with the Company in a timely manner
following your military service. See “Leaves of Absence and Layoff” on page 156 for more information.
Call Fidelity Customer Service at (800) 835-5092 or go online at www.401k.com for more information about in-
service Plan loans.

IF YOU LEAVE UHS WITH AN OUTSTANDING LOAN

If you end employment while your loan is outstanding, you may continue to repay the loan based on the same
repayment schedule directly to Fidelity. If you end employment and take a distribution before your loan is
fully repaid, your distribution will be reduced by the outstanding principal and you will no longer be able to
repay the loan.

AGE 59½ IN-SERVICE DISTRIBUTIONS

When you reach age 59½, you can withdraw all or any portion of your vested Plan account at any time,
without penalty, by visiting www.401k.com or by calling Fidelity Customer Service at (800) 835-5092. The
minimum withdrawal you may request is $250.

ACTIVE MILITARY DUTY WITHDRAWALS

If you are on a qualified military leave of absence, you can withdraw all or a portion of your account in the
Plan. If you make a withdrawal, you will be suspended from making contributions to the Plan for six months.
See “Leaves of Absence and Layoff” on page 156 for more information.
If you are performing active duty service in the reserves or National Guard for at least 180 days, you may
withdraw all or any portion of your contribution accounts. Your future contributions to the Plan will not be
suspended. Contact Fidelity for more information about active duty Plan withdrawals.

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HARDSHIP WITHDRAWAL
Generally, you may make a hardship withdrawal of a portion of your contributions, rollover contributions and
Company matching contributions, if applicable, regardless of your age. This is provided the amount requested
is necessary to meet an immediate and heavy financial need. You must have exhausted all other possible
means of available resources, such as loans from non-Plan sources, savings accounts and liquidation of other
assets before obtaining a hardship withdrawal. An immediate and severe financial reason can be one or more
of the following:
 purchase of a principal residence (excluding mortgage payments),
 payment of post-secondary tuition and related fees for the next 12 months for you or an eligible
dependent,
 prevention of eviction from your principal residence or foreclosure on the mortgage of your principal
residence,
 payment of medical expenses that are not reimbursed through your medical plan,
 payments for burial or funeral expenses for your deceased parent, spouse or child, or
 expenses for the repair of damage to your principal residence that would qualify for the casualty loss
deduction under Section 165 of the Internal Revenue Code (determined without regard to whether the
loss exceeds 10% of your adjusted gross income).
Hardship withdrawals may also be permitted by the Federal Emergency Management Agency (FEMA) on a
selective basis in conjunction with certain natural disasters as declared by the IRS and adopted by the Plan
from time to time.
The minimum hardship withdrawal is $250 and you are limited to no more than two hardship withdrawals per
calendar year.
You may only withdraw the amount necessary to meet your immediate need, and documentation of your
need must be provided on request (such as a copy of the student’s tuition bill). Call Fidelity Customer Service
at (800) 835-5092 to initiate a hardship withdrawal.

EARLY WITHDRAWAL TAX PENALTY

In addition to federal income tax and possibly state and/or local tax, you will be required to pay a 10%
additional penalty tax on early distributions unless:
 payments made after you separated from service if you will be at least age 55 in the year of the
separation,
 payments that start after you separate from service if paid at least annually in equal or close to equal
amounts over your life or life expectancy (or the joint lives or joint life expectancies of you and your
beneficiary),
 payments made due to disability

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 payments after your death,

 corrective distributions of contributions that exceed tax law limitations,
 payments made directly to the government to satisfy a federal tax levy,
 payments made under a qualified domestic relations order (QDRO),
 certain payments made while you are on active duty if you were a member of a reserve component called
to duty after September 11, 2001 for more than 179 days.
If you receive a distribution of your account upon termination of employment before age 55, the 10%
additional penalty tax on early distributions will not apply if you roll the taxable money into another eligible
retirement plan or an IRA or Roth IRA within 60 days after you receive it.
Tax laws that apply to plan withdrawals and distributions are complex and change from time to time. You
should check with a financial advisor or accountant when deciding how to receive a payout of your account.

WITHDRAWALS FROM ROLLOVER AND PRIOR PLAN SUBACCOUNTS

If you have a rollover account or if UHS merged or transferred assets from your prior employer-sponsored
retirement plan to the 401(k) Plan, except as otherwise provided in the terms of your prior plan, you may
withdraw the entire value of your rollover account and prior plan subaccount at any time in accordance with
IRS regulations. However, if your rollover account and prior plan subaccount contains merged or transferred
assets from a prior retirement plan that was subject to the minimum funding rules and the joint and survivor
distribution rules, those amounts may not be available for withdrawals.

DISTRIBUTIONS WHEN YOU LEAVE THE COMPANY

Your vested account balance in the Plan is payable upon:
 normal retirement,
 early retirement,
 deferred retirement,
 disability retirement,
 termination of your employment, or
 your death.
When you leave UHS, you have to make a decision about your Plan account balances. In general, you can:
 Transfer balances to another employer’s tax-qualified plan that accepts rollovers, an individual retirement
account (IRA) or Roth IRA, if applicable.
 Take a cash payment of the full amount, less any required income taxes. You may still owe additional
income taxes on your payment, and possibly a 10% penalty tax for early withdrawal.
 Take a partial cash payment and rollover the remaining amount.

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 Take your account balance in a series of monthly payments not more than the lesser of:
 10 years, or
 the joint life expectancy of you and your beneficiary.
 Leave it in the Plan until you reach age 72, with the option to withdraw it at any earlier time. You can only
leave it in the Plan if your account balances are more than $7,000. If you were born on or before June 30,
1949, the applicable age is 70½.
If you plan to transfer your funds to another tax-deferred plan or IRA, be sure to read the important
information in the Special Tax Notice that will be provided to you after you terminate employment when
requesting a distribution or rollover of your vested account balance. You must call Fidelity Customer Service at
(800) 835-5092 to request a distribution of your account balance.
The federal income tax aspects of payments from the 401(k) Plan are complex and subject to change. In
addition, applicable tax treatment under state and local law may differ. You may wish to consult your tax
advisor regarding the financial impact of any distributions that you receive from the 401(k) Plan.

PAYMENT OF PRIOR PLAN SUBACCOUNTS

If UHS merged or transferred assets from your prior employer-sponsored retirement plan to the 401(k) Plan,
the terms of your prior plan subaccount determine when and how distributions from your prior plan
subaccount may be made.
For more information about prior plan subaccounts, contact Fidelity at Fidelity Customer Service (800) 835-
5092.

IF YOU RETIRE
You will be considered to have "retired" if one of the following occurs:
 your employment with the Company ends on or after age 65 (normal retirement age),
 your employment with the Company ends on or after age 55 (early retirement age), or
 You are considered disabled under the provisions of the Company's long-term disability plan or are eligible
for Social Security disability.
If you "retire" and your account balance (including the balance in your rollover contributions account) is more
than $7,000, you can choose to defer distribution of your account balance until you reach the age of 72. You
will have the option to withdraw your account balance (in whole) at any earlier time.

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WHEN YOU DIE

If you die before terminating employment with UHS, your Plan account will become 100% vested on the date
of your death, and all amounts credited to your Plan accounts will be paid as soon as administratively possible
to your designated beneficiary.
If you die after terminating employment with UHS, the portion of your account balances that was vested as of
your termination date (less any payments that you may have previously received) will be paid as soon as
administratively possible to your designated beneficiary, subject to any applicable survivor annuity rules.
In general, your beneficiary (or beneficiaries) will receive the balance in your account in a single lump sum
after your death. However, if you were receiving monthly payments at the time of your death, your
beneficiary may choose to continue receiving any installment payments that remained unpaid as of your date
of death.
Your beneficiary (or beneficiaries) must contact Fidelity to initiate a distribution. A certified copy of the death
certificate will be required.
These payments will be subject to applicable income taxes and may also be subject to estate taxes.

WHEN YOU REACH AGE 72

In general, you must begin taking distributions from your Plan account by April 1 following the year in which
you reach age 72, or when you retire, whichever is later. You may choose to receive your entire account
balance in a single lump sum or you may withdraw the required minimum distribution.
If you’re age 72 or older and still actively working, you may be able to delay taking a required distribution from
the Plan. Visit www.401k.com or call Fidelity at (800) 835-5092 for more information.

IF YOUR ACCOUNT BALANCE IS LESS THAN $7,000

If your vested account balance of $1,000 or less when your employment ends and you do not make an
affirmative election to receive the distribution or to roll it over into another employer’s qualified retirement
plan, IRA or Roth IRA, your benefit will be paid directly to you (or your beneficiary) in a lump sum as soon as
possible without your consent.
If you end employment with a vested account balance of more than $1,000 but not more than $7,000, you
may elect whether to receive the distribution or to roll it over. However, if you fail to make an affirmative
election, the law allows the Plan Administrator to automatically roll over your distribution into an IRA or Roth
IRA (an “automatic rollover”).

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The IRA provider must invest the automatic rollover in an investment fund designed to preserve principal and
provide you with a reasonable rate of return and liquidity (such as an interest-bearing account, a certificate of
deposit, or a money market fund). The IRA provider chosen by the Plan Administrator is:
Fidelity Investments
P.O. Box 770001
Cincinnati, OH 45277-0002
(800) 544-5650
You will be provided with information regarding the IRA at the time you are entitled to a distribution. Fidelity
will charge your account for reasonable expenses associated with the establishment and maintenance of the
IRA or Roth IRA and its investments. Contact Fidelity for further information regarding the Plan's automatic
rollover provisions, the IRA provider, and the fees and expenses associated with the IRA.
You may transfer your Fidelity IRA or Roth IRA funds at any time and without additional fees from Fidelity. You
may transfer the funds to any other IRA or Roth IRA you choose or to another employer’s qualified plan that
will accept such transfer. Please note that the institutions accepting your funds may charge additional fees.

TAXES ON YOUR DISTRIBUTION

Payments that are not rolled over to another employer’s tax-qualified plan, IRA or Roth IRA and are instead
paid directly to you generally will have federal income taxes withheld at a rate of 20% of the taxable portion of
the payment as required by law.
You will receive a Special Tax Notice Regarding Plan Payments when you apply for a distribution. If you receive
a payment before you reach age 59½, you may be subject to a 10% penalty tax imposed by the IRS unless an
exception applies. It is recommended that you consult with a qualified tax advisor before requesting payment.

UNDERSTANDING YOUR 401(K) PLAN PARTICIPATION

You must meet certain criteria to participate in the Plan.

IF YOU LEAVE UHS AND ARE REHIRED

If you are fully or partially vested in your account and you end employment with UHS and are later rehired,
your lost credited service will be added to your account provided you are rehired before your break-in-service
equals or exceeds the greater of five years or the number of years of credited service you had before your
break. See “Credited Service” on page 155 for more information.
If you receive a distribution of your vested account after your employment with UHS ends, and then you are
rehired before you have five consecutive one-year breaks-in-service, you will be able to repay the amount you
received back into the Plan. This repayment must occur by the earlier of (a) the date on which you would have
incurred five consecutive one-year breaks-in-service, or (b) five years from the date you resume employment.

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Upon repayment, any forfeited amounts will be restored to your account and invested at your direction once
you notify Fidelity. See “Break in Service” on page 155 for more information.
If you do not repay the amount distributed to you within the allowable time period, forfeited amounts will not
be restored.
If your employment ends while you are a participant in the Plan and you are rehired in an eligible status within
30 days of your termination, you may rejoin the Plan as of the beginning of any pay period following your date
of rehire.
If your employment ends while you are a participant in the Plan and you are rehired more than 30 days after
your termination, or if your employment ends before you are eligible, you will have to meet the eligibility
requirements as a new employee to enroll in the Plan.

CREDITED SERVICE
Your credited service is used to determine your eligibility to participate in the Plan and vested interest in
Company matching contributions.
You earn credited service during your employment with UHS and its affiliates as follows:
 One year of credited service is the completion of 1,000 hours of service within a calendar year.
 One day of credited service is one shift or scheduled day of work in which you are paid or entitled to pay
from UHS, including holidays, vacation, disability, illness, layoff, jury duty, leave of absence, or military
service.
See “Break in Service,” below, for more information about how an absence from work may affect your vesting
status.

BREAK IN SERVICE
Sometimes your service with the Company is interrupted or broken. A break in service typically occurs when
you have worked less than 501 hours of service in the calendar year.
You will have a break in service:
 on the last day you work for the Company if you resign, are discharged, retire or die
 if you are disabled and do not return to work when your disability ends, or the date you retire, whichever
occurs first
 if you are on a military leave of absence and do not return to work within the specified period of time as
required by the law pertaining to veterans' re-employment rights
 if you are on an approved leave of absence or layoff and do not return to work by the scheduled end of
your approved leave.

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Break in Service rules are complex. The above explanation is only a summary. If you have questions regarding
Break in Service rules, please contact Fidelity.

LEAVES OF ABSENCE AND LAYOFF

A break in service can be prevented if you are on an approved leave of absence. If you do not return to work
at the expiration of your leave of absence, you will be considered to have terminated employment on the date
of the expiration of your leave of absence.
 Approved Leaves of Absence: If you are on an approved leave of absence of up to one year, you will get
credit for the time off to prevent a break-in-service from occurring just as though you were actively at
work, provided you return to work at the end of your approved leave.
 Military Leave of Absence: If you take a leave of absence for military service, special break in service rules
apply. If you are a veteran and are reemployed under the Uniformed Services Employment and
Reemployment Rights Act of 1994 (USERRA), your qualified military service may be considered service with
the Company. You may have other special rights or benefits if you die or become disabled while on active
duty. To receive special rights under USERRA, before taking military leave, you must provide UHS with
written or oral notice that you are leaving to perform military service, unless you are unable to do so due
to military necessity or it is otherwise impossible or unreasonable.
 Layoff: If you are laid off for up to one year, you will receive credit for service to prevent a break-in-service
from occurring.
If you think you may be affected by these rules, please contact your local Human Resources Department for
more information.

PLAN ADMINISTRATION INFORMATION

This section contains other important administrative details about your 401(k) Plan and a brief explanation of
your rights under the Employee Retirement Income Security Act of 1974 (ERISA). This section, along with the
401(k) Plan benefit information described in the rest of this Summary Plan Description (SPD), form an ERISA
SPD for the 401(k) Plan.
Every effort has been made to describe the 401(k) Plan as clearly and accurately as possible. However, the
401(k) Plan is governed by master contracts and plan documents. If there is a difference of opinion or question
about a benefit determination, the legal contracts and plan documents will govern. You may request copies of
all 401(k) Plan contracts and plan documents, without charge, by contacting the Plan Administrator.
UHS maintains the 40(k) Plan for the exclusive benefit of employees; however, eligibility for, or participation
in, the 401(k) Plan is not an assurance or guarantee of continued employment. The term “Universal Health
Services, Inc.” used throughout the SPD refers to Universal Health Services, Inc. and its subsidiary companies
that have adopted this 401(k) Plan.

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Employer Identification Number

Universal Health Services, Inc: 23-2077891

Plan Number
The Plan number is 001.

Plan Year
The Plan Year is the 12-month period beginning on January 1 and ending on December 31. For purposes of
administering the Plan, the books and financial records are maintained on a Plan Year basis.

Plan Administrator
Universal Health Services, Inc. and its authorized representatives appointed by the Board of Directors are the
Plan Administrators.
You can contact the appointed representatives by writing or calling the Benefits Department at Universal
Health Services, Inc., 367 South Gulph Road, King of Prussia, PA 19406; (610) 768-3300.

Plan Sponsor
Universal Health Services, Inc. sponsors the 401(k) Plan for eligible employees at participating companies and
hospitals affiliated with Universal Health Services, Inc.

Plan Fiduciary
Universal Health Services, Inc. and its authorized representatives appointed by the Board of Directors are the
Plan Fiduciaries. The fiduciaries are responsible for the proper administration of the Plan according to the
terms of ERISA and any documents or contracts. The fiduciaries generally supervise the operation of the
Plan — interpreting its provisions, coordinating retirements, and authorizing all benefit payments.
You can contact the appointed representatives by writing or calling the Benefits Department at Universal
Health Services, Inc., 367 South Gulph Road, King of Prussia, PA 19406; (610) 768-3300.

Plan Trustee
The Plan Trustee is:
Fidelity Management Trust Company
82 Devonshire Street
Boston, MA 02190.

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General Counsel
Service of legal process may be made to the Plan Administrator at the following address:
General Counsel
Universal Health Services, Inc. c/o
Corporation Services Company
2595 Interstate Drive
Suite 103
Harrisburg, PA 17110
Legal process may also be served on the Plan Trustee.

Plan Funding
The Plan is funded by employee and employer contributions. However, the IRS considers employee
contributions to be employer contributions for tax purposes.
All assets are received and distributed by the Plan Trustee for the exclusive purpose of providing benefits to
participants and beneficiaries of the Plan and paying reasonable Plan expenses.

Duties of the Plan Administrator

The Plan Administrator is responsible for the general administration and management of the Plan. The Plan
Administrator has all the powers and duties necessary to fulfill his or her responsibilities including, but not
limited to the following powers and duties: (a) selecting and removing Plan trustees, investment media,
recordkeepers, and/or insurance companies; (b) the amendment of the Plan and trust agreement or insurance
contract; (c) the termination of the Plan; and (d) the merger or consolidation of the Plan with or transfer of
Plan assets to another qualified retirement plan.

Plan Summary and Official Plan Text

This SPD is a brief description of your 401(k) Plan and your rights, obligations, and benefits under this Plan.
Some of the statements made in this SPD are dependent upon this Plan being “qualified” under the provisions
of the Internal Revenue Code. This SPD is not meant to interpret, extend, or change the provisions of your Plan
in any way. The provisions of your Plan may only be determined accurately by reading the actual Plan
document. Copies of the SPD, the Plan document, and the latest annual report filed with the Department of
Labor are available for your inspection during normal working hours in the Human Resources Department. You
may also obtain a copy of the Plan document at a reasonable cost from the Plan Administrator. If you have any
questions regarding either the Plan or this SPD, you should contact the Plan Administrator. In the event of any
discrepancy between this SPD and the actual provisions of the Plan, the Plan document shall govern.

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NON-ASSIGNMENT OF BENEFITS
Your account under the Plan may not be assigned, sold, transferred, garnished, or pledged as collateral, nor
may a creditor attach your account in the Plan as a means of collecting a debt owed by you.
However, your account can be attached to satisfy a federal tax levy and state courts can rule that benefits be
paid to someone other than you or your named beneficiary, according to a Qualified Domestic Relations Order
(QDRO) that relates to child support, alimony, or marital property rights. See “Qualified Domestic Relations
Order” below for more information.

PLAN TERMINATION INSURANCE

The benefits under this Plan are not insured by the Pension Benefit Guaranty Corporation (PBGC) under Title
IV of Employee Retirement Income Security Act of 1974, (ERISA) because the Plan is a defined contribution
plan to which that requirement of the law does not apply.

FUTURE OF THE PLAN

While UHS intends to continue this Plan indefinitely, it is difficult to predict the future; therefore, an
unqualified commitment is impossible. Thus, UHS reserves the right to modify, suspend, or terminate the Plan,
or any portion of the Plan, at any time and for any reason.
Any amendment, however, may not deprive you of any benefits under the Plan to which you are entitled at
the time. Should the Plan terminate while you are employed, you will be 100% vested in your account balance
and all accounts will be restricted exclusively for distribution to participants and beneficiaries in accordance
with Plan provisions.

TOP HEAVY PROVISIONS

If the Plan is deemed to be “top heavy” according to IRS regulations, certain provisions of the Plan may take
effect automatically. These changes may include an increased benefit, and an upper limit on compensation
used in computing benefits. Generally, a plan is top heavy if certain owners and officers of the employer have
earned more than 60% of the account balances under the Plan. In the unlikely event that the Plan becomes
top-heavy, the special provisions that will take effect are designed to protect the rights of employees who are
not owners or officers.

QUALIFIED DOMESTIC RELATIONS ORDER

If you divorce, or if you become liable for support or alimony payments, a court may issue a Qualified
Domestic Relations Order (a “QDRO”) that legally requires the Plan to pay all or a portion of your account
balance to your spouse, ex-spouse, children or other dependent (an “Alternate Payee”). You will be notified if

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a domestic relations order relating to your benefits is received by the Plan Administrator. You may obtain a
copy, free of charge, of the procedures relating to QDROs by calling Fidelity Investments at (800) 835-5092.

CLAIMS
If you believe you are entitled to a benefit under the Plan, you or your authorized representative acting on
your behalf may make a claim for benefits.

FILING A CLAIM
Your claim for benefits must be made in accordance with the procedures established by the Plan
Administrator. You can obtain the necessary assistance from Fidelity. Within 90 days after receiving the claim,
the Plan Administrator will review your claim and notify you of its determination. If the Plan Administrator
determines that more time is needed to properly review your claim, you will receive a written notice before
the end of the initial 90 day review period that will tell you the reasons why the extension is necessary and the
date by which the Plan Administrator expects to complete the review and make a decision. The extension of
the review period may not last more than 180 days from the day the Plan Administrator received your original
claim for benefits.

IF YOUR CLAIM IS DENIED

If your claim for Plan benefits is denied in whole or in part, you have the right to request a claim review if you
disagree with the decision. The notice of denial will include:
 the specific reason for the denial;
 the specific Plan provisions on which the denial is based;
 a request for any additional information required to reconsider the claim and an explanation of why this
information is needed; and
 an explanation of the Plan’s appeal procedure.
You have the right to review all documentation which was used to make the decision about your claim.

LITIGATION AFTER FINAL APPEAL

If your appeal is denied, you may bring a legal action to have a court review your claim denial. You must bring
this action within 90 days after receiving notice of the denial of your appeal. If you do not file a lawsuit within
this time frame, you will never be able to bring a legal action relating to the benefit that was denied, at any
time in the future. You may not bring legal action until you have first exhausted your claim and appeal rights.
All interpretations by the Plan Administrator will be final and binding.
The claims procedure outlined above applies to you, your beneficiary, or any other person who has a right to
benefits under the Plan.

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APPENDIX A – PARTICIPATION FROM A PRIOR PLAN

Plan Name Date Your Prior Plan Merged with This Plan
HRI Retirement Plan for Non-Bargaining Employees January 1, 1987
HRI Retirement Plan for Bargaining Employees January 1, 1993
Desert Springs 401(k) July 1, 1999
The National Deaf Academy, LLC 401(k) Plan December 31, 2011
Psychiatric Solutions, Inc. Retirement Savings Plan December 31, 2011
Ascend Health Corporation 401(k) Profit Sharing Plan and Trust April 15, 2013
McAllen Medical Center Physicians, Inc. 401(k) Profit Sharing Plan April 15, 2013
The Psychiatric Institute of Washington 401(k) Plan December 31, 2014
Foundations Recovery Network 401(k) Profit Sharing Plan April 1, 2016

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This section contains important information about your benefit plans, which are
described in detail in this Summary Plan Description (SPD). A brief explanation of
your rights under the Employee Retirement Income Security Act of 1974 (ERISA) is
also presented here.
Every effort has been made to write the descriptions of the available benefits as clearly and accurately as
possible. However, the plans are each governed by master insurance policies, contracts, and/or plan
documents. If there is a difference of opinion or question about a benefit determination, the legal contracts
and plan documents will govern. You may request copies of all benefit schedules, insurance policies, and
contracts, without charge, by contacting the Plan Administrator.
Universal Health Services, Inc. (UHS) maintains the benefits program for the exclusive benefit of employees;
however, eligibility for, or participation in, the UHS benefit plans is not an assurance or guarantee of
continued employment. The term “Universal Health Services, Inc.” used throughout the SPD refers to UHS and
its subsidiary companies that have adopted one or more of these plans.
Note that by adopting and maintaining these benefits, UHS has not entered into an employment contract with
any employee. Nothing in the legal Plan documents or in the SPD gives any employee the right to be employed
by UHS or to interfere with UHS' right to discharge any employee at any time. Providing this SPD to you does
not entitle you to benefits for which you are otherwise not eligible.

In this Section
Plan Sponsor and Administrator .................................................................................................................................................... 163
The Employer Identification Numbers (EIN) .................................................................................................................................. 163
The Plan Numbers ......................................................................................................................................................................... 164
The Plan Year End.......................................................................................................................................................................... 164
Plan Administrator and Plan Sponsor ............................................................................................................................................ 164
General Counsel ............................................................................................................................................................................ 164
Plan Funding.................................................................................................................................................................................. 164
Claims Administrators ................................................................................................................................................................... 165
Duties of the Plan Administrator .................................................................................................................................................... 165
Plan Amendment and Termination ............................................................................................................................................... 165
Plan Interpretation ........................................................................................................................................................................ 166
Plan Document .............................................................................................................................................................................. 166
Federal Notices.............................................................................................................................................................................. 166
Qualified Medical Child Support Orders ......................................................................................................................................... 166
The Newborns’ and Mothers’ Health Protection Act ..................................................................................................................... 167

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The Women’s Health and Cancer Rights Act .................................................................................................................................. 167

Claims Appeals .............................................................................................................................................................................. 168
Health Claim Filing and Appeal Procedures ................................................................................................................................... 169
Adverse Benefit Determination ...................................................................................................................................................... 169
Notice of Claim Determination ....................................................................................................................................................... 170
If a Claim Is Denied ......................................................................................................................................................................... 171
Claim Appeals Procedures .............................................................................................................................................................. 172
Notice of Appeal Determination ..................................................................................................................................................... 174
If an Appeal Is Denied ..................................................................................................................................................................... 175
Non-Health Claim Filing and Appeal Procedures............................................................................................................................ 176
Notice of Claim Determination ....................................................................................................................................................... 177
If a Claim Is Denied ......................................................................................................................................................................... 177
Claims Appeals Procedures ............................................................................................................................................................. 177
Notice of Appeal Determination ..................................................................................................................................................... 177
If an Appeal Is Denied ..................................................................................................................................................................... 178
Statement of ERISA Rights ............................................................................................................................................................. 178
Schedule of Insurance Carriers or Claims Administrators .............................................................................................................. 180
Employee Privacy Notice ............................................................................................................................................................... 182
Communication with You ............................................................................................................................................................... 182
UHS’ Pledge Regarding Health Information Privacy ....................................................................................................................... 183
Privacy Obligations of the Plan ....................................................................................................................................................... 183
How the Plan May Use and Disclose Health Information About You ............................................................................................. 183
Special Use and Disclosure Situations ............................................................................................................................................ 184
Your Rights Regarding Health Information About You ................................................................................................................... 185
Changes to this Notice .................................................................................................................................................................... 185
Complaints ...................................................................................................................................................................................... 186
Other Uses and Disclosures of Health Information ........................................................................................................................ 186
Contact Information ....................................................................................................................................................................... 186

PLAN SPONSOR AND ADMINISTRATOR

The plans described in this SPD are established, maintained, and adopted by:
Universal Health Services, Inc.
367 S. Gulph Road
P.O. Box 61558
King of Prussia, PA 19406-0958
(610) 768-3300

THE EMPLOYER IDENTIFICATION NUMBERS (EIN)

Universal Health Services, Inc.: 23-2077891

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THE PLAN NUMBERS

 UHS Retirement Savings Plan: 001
 UHS Welfare Benefit Plans: 512

THE PLAN YEAR END

 UHS Retirement Savings Plan: 12/31
 UHS Welfare Benefit Plans: 12/31

PLAN ADMINISTRATOR AND PLAN SPONSOR

UHS is both the Plan Administrator and Plan Sponsor for all plans, unless noted otherwise.
All plan administration is done at:
367 S. Gulph Road
King of Prussia, PA 19406
(610) 768-3300
Plan Administrators may also be reached at this office.
The Plan Administrator has the authority to control and manage the operation and administration of the Plan
and may delegate internally or to a third party any duties or responsibilities, as they deem appropriate. The
agent for service of legal process is the Plan Administrator. Service of legal process may also be made upon the
Plan Administrator or any Plan trustee. Legal process for the Plan Administrator must be directed to:

GENERAL COUNSEL
Plan Administrator indicated above c/o:
Corporation Service Company
2595 Interstate Drive
Suite 103
Harrisburg, PA 17110

PLAN FUNDING
This benefit Plan is financed by employer and employee contributions.
The Plan Administrator will notify employees annually as to what the employee contribution rates will be.
UHS, in its sole and absolute discretion, shall determine the amount of any required contributions under the
Plan and may increase or decrease the amount of the required contribution at any time. Any refund, rebate,
dividend, experience adjustment, or other similar payment under a group insurance contract shall be applied

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first to reimburse UHS for its contributions, unless otherwise provided in that group insurance contract or
required by applicable law.

CLAIMS ADMINISTRATORS
The insurance companies or agents for processing claims are listed in the schedule following this section,
under “Schedule of Insurance Carriers or Claims Administrators” on page 180.

DUTIES OF THE PLAN ADMINISTRATOR

The Plan Administrator shall be responsible for the general administration and management of the Plan and
will be the fiduciary to the extent not otherwise specified in the SPD. The Plan Administrator shall have all the
powers and duties necessary to fulfill his or her responsibilities including, but not limited to, the following
powers and duties: (a) to construe and interpret the Plan as he or she, in his or her sole discretion, deems to
be appropriate; and (b) to determine all questions relating to the eligibility of persons to participate or receive
benefits as he or she, in his or her sole discretion, deems to be appropriate.
UHS may designate other organizations or persons to carry out specific fiduciary responsibilities for UHS in
administering the Plan including, but not limited to, the following:
 pursuant to an administrative services or claims administration agreement, if any, the responsibility for
administering and managing the Plan, including the processing and payment of claims under the Plan and
the related recordkeeping;
 the responsibility to prepare, report, file and disclose any forms, documents, and other information
required to be reported and filed by law with any governmental agency, or to be prepared and disclosed to
employees or other persons entitled to benefits under the Plan; and
 the responsibility to act as Claims Administrator and to review claims and claim denials under the Plan to
the extent an insurer or administrator is not empowered with such responsibility.
UHS will administer the Plan on a reasonable and nondiscriminatory basis and shall apply uniform rules to all
persons similarly situated.

PLAN AMENDMENT AND TERMINATION

The right is reserved in the Plan for the Plan Administrator to amend, terminate, suspend, withdraw, or modify
the Plan in whole or in part at any time and for any reason, subject to the applicable provisions of the Plan
document and regardless of your status at the time of the change.
Any action by the Plan Administrator under this Plan shall be, by duly adopted resolution of the Board of
Directors of the Plan Sponsor, or by any person or persons duly authorized by a duly adopted resolution of the
Board of Directors, to take such action.

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PLAN INTERPRETATION
The Plan shall be interpreted by the Plan Administrator in accordance with its terms. However, the Plan
Administrator (or its delegate) shall have the discretion to make any findings of fact needed in the
administration of the Plan, and shall have the discretion to interpret or construe ambiguous, unclear or
implied (but omitted) terms in any fashion that he or she deems appropriate in his or her sole judgment.
To the extent the Plan Administrator (or his or her delegate) has been granted discretionary authority under
the Plan, the Plan Administrator’s prior exercise of such authority shall not obligate him or her to exercise his
or her authority in a like fashion thereafter.
If, due to error in drafting, any provision of the Plan does not accurately reflect its intended meaning, as
demonstrated by consistent interpretations or other evidence of intent, the provision shall be considered
ambiguous and shall be interpreted by the Plan Administrator in a fashion consistent with its intent. A
misstatement or other mistake of fact will be corrected when it becomes known, and UHS will make such
adjustment on account of the mistake as it considers equitable and practicable, in light of applicable law. All
actions taken and determinations made by the Plan Administrator shall be final and binding upon all persons
claiming any interest in or under the Plan.
UHS, separately and in its role as Plan Administrator will not be liable in any manner for any determination
made in good faith.

PLAN DOCUMENT
This document is intended merely as a summary of the Plan document(s), insurance carrier certificates and/or
plan contracts. In the event of any disagreement between this summary and the Plan document(s), insurance
carrier certificates and/or plan contracts as they may be amended from time to time, the provisions of those
documents will govern.

FEDERAL NOTICES
The Plan is required to provide you with the following federal notices.

QUALIFIED MEDICAL CHILD SUPPORT ORDERS

For purposes of health benefits under the Plan, the term “dependent” also includes any child for whom an
employee is required to provide medical coverage under a Qualified Medical Child Support Order (QMCSO). A
QMCSO is any judgment, decree, or order (including a court-approved settlement agreement), issued by a
court of competent jurisdiction or through an administrative process under state law which has the force and
effect of law in that state, which creates or recognizes the right of a child to, or assigns to such child the right
to, receive health benefits for which a participant is eligible under the Plan, and that the Plan Administrator

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determines to be qualified under the Employee Retirement Income Security Act of 1974 (ERISA) and applicable
state law.
The effective date of coverage for the child shall be the date specified in the QMCSO, or if none, the date of
the QMCSO.
Coverage under the Plan can be extended to a child who is covered by a QMCSO, if:
 the QMCSO is issued on or after the date your coverage becomes effective, and
 your child meets the definition of an eligible dependent under the Plan.*
You may obtain a copy of UHS’ QMCSO procedures, free of charge, by calling the UHS Benefits Service Center
at (855) 847-2002.
* Children who may be covered under a QMCSO include foster children, those not claimed as dependents on your federal income tax return,
and children who do not reside with you. However, a child who is no longer eligible, due to his or her age, for example, cannot be added under
a QMCSO.

THE NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT

Federal law generally prohibits restricting benefits for hospital lengths of stay to less than 48 hours following a
vaginal delivery and less than 96 hours following a caesarean section. However, the Plan may pay for a shorter
stay if the attending provider (physician, nurse midwife, or physician assistant) discharges the mother or
newborn earlier, after consulting with the mother.
Also, federal law states that plan benefits may not, for the purpose of benefits or out-of-pocket costs, treat
the later portion of a hospital stay in a manner less favorable to the mother or newborn than any earlier
portion of the stay.
Finally, federal law states that a plan may not require a physician or other healthcare provider to obtain
authorization of a length of stay up to 48 hours or 96 hours, as described above. However, to use certain
providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain precertification.

THE WOMEN’S HEALTH AND CANCER RIGHTS ACT

In accordance with the Women’s Health and Cancer Rights Act, this Plan covers the following procedures for a
person receiving benefits for an appropriate mastectomy:
 reconstruction of the breast on which a mastectomy has been performed
 surgery and reconstruction of the other breast to create a symmetrical appearance
 prostheses
 treatment of physical complications of all stages of mastectomy, including lymphedemas.
This coverage will be provided in consultation with the attending physician and the patient, and will be subject
to the same annual deductibles and coinsurance provisions that apply to the mastectomy.

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The Plan may consider breast reconstruction following lumpectomy based on medical necessity criteria as
established by the Claims Administrator.

CLAIMS APPEALS
The claim-filing procedures for each type of benefit are outlined in the individual sections describing the
benefits. Usually your provider files an electronic claim for you and your covered dependents, or designated
beneficiary (when applicable). However, you are ultimately responsible to ensure a claim has been filed. Claim
forms are available from the applicable carrier.
The booklets and other materials that describe a particular benefit under the Plan will generally contain a
specific set of claims and appeals procedures that you must follow to make a claim to receive that particular
benefit and/or to appeal a denied claim for that particular benefit. Although these separate claims and
appeals procedures will be very similar in most respects, there may be important differences. Because of this,
you should follow the specific claims and appeals procedures for a particular benefit very carefully. If the
booklets and other materials that describe a particular benefit do not contain a specific set of claims and
appeals procedures, the Plan’s default procedures as described below will apply. If you have any questions
about which set of claims and appeals procedures to follow or any other questions about making a claim, you
should contact the Plan Administrator immediately.
For purposes of this section of the SPD describing the Plan’s default claims and appeals procedures, the third
parties to whom the Plan Administrator has delegated the authority to review and evaluate claims (in the case
of the self-insured plans) and the insurance carriers (in the case of the insured plans) shall be referred to as
the “Claims Administrator” at the initial claim level and the “Appeals Administrator” at the appeal level.
A request for benefits is a “claim” subject to these procedures only if you or your authorized representative
file it in accordance with the Plan’s claim filing guidelines. In general, claims must be filed in writing (except
urgent care claims, which may be made orally) with the applicable provider identified in the “Self-Insured
Plans” and “Insured Plans” charts later in this section. Any claim that does not relate to a specific benefit
under the Plan (for example, a general eligibility claim) must be filed with the Plan Administrator at the
address set forth in the “General Plan Information” section below. A request for prior approval of a benefit or
service where prior approval is not required under the Plan is not a “claim” under these rules. Similarly, a
casual inquiry about benefits or the circumstances under which benefits might be paid under the Plan is not a
“claim” under these rules, unless it is determined that your inquiry is an attempt to file a claim. If a claim is
received but there is not enough information to allow the Claims Administrator to process the claim, you will
be given an opportunity to provide the missing information.
If you want to bring a claim for benefits under the Plan, you may designate an authorized representative to act
on your behalf as long as you provide written notice of such designation to the Claims Administrator and/or
the Appeals Administrator identifying such authorized representative. In the case of a claim for medical
benefits involving urgent care, a healthcare professional with knowledge of your medical condition may act as
your authorized representative with or without prior notice.

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HEALTH CLAIM FILING AND APPEAL PROCEDURES

In the case of a claim involving health benefits (e.g., medical, supplemental insurance, dental, vision, and
Health Care FSA or Limited Purpose FSA), initial claims for benefits under the Plan should be made by you in
writing to the Claims Administrator.
There are several different types of health claims that you may bring under the Plan. The Plan’s procedures for
evaluating claims (for example, the time limits for responding to claims and appeals) depend upon the
particular type of claim. Claims must contain, at a minimum, the name of the individual for whom benefits are
being claimed, a specific medical condition or symptom, and a specific treatment, service, or product for which
payment is being requested.
The types of claims that you generally may bring under the Plan are as follows:
 Pre-Service Claim: A claim for a particular benefit under the Plan that requires advance approval and must
be filed before you receive the benefit.
 Urgent Care Claim: A pre-service claim for medical care or treatment with respect to which the regular,
pre-service claim timeframes could jeopardize your life, health, or ability to regain maximum function, or
would subject you to severe pain that cannot be adequately managed without the claimed care or
treatment. A claim shall be treated as an urgent care claim automatically if a physician with knowledge of
your medical condition determines the claim involves urgent care.
 Post-Service Claim: A claim for payment for a particular benefit or for a particular service after the benefit
or service has been provided. A post-service claim must contain the information requested on a claim form
provided by the applicable provider.
 Concurrent Care Review Claim: A claim relating to an ongoing course of treatment, including treatment
provided over a period of time; a specified number of treatments; or a requested extension beyond the
initially approved period of time or number of treatments.
Generally, the claim type is determined initially when the claim is filed. However, if the nature of the claim
changes as it proceeds through these claims procedures, the claim may be recharacterized. For example, an
initially-determined urgent care claim is recharacterized as a pre-service claim if the urgency subsides.

ADVERSE BENEFIT DETERMINATION

If the Plan does not fully agree with your claim, you will receive an “adverse benefit determination” — a
denial, reduction, or termination of a benefit, or failure to provide or pay for (in whole or in part) a benefit. An
adverse benefit determination includes a decision to deny benefits based on:
 an individual being ineligible to participate in the Plan;
 utilization review;
 a service being characterized as experimental or investigational or not medically necessary or appropriate;
and
 a concurrent care decision.

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An adverse benefit determination for medical benefit claims includes a rescission of coverage (generally a
retroactive cancellation of coverage) under the Plan, whether or not in connection with the rescission there is
an adverse effect on any particular benefit at that time. However, if the plan retroactively cancels coverage for
failure to pay required contributions, that is not an adverse benefit determination.

NOTICE OF CLAIM DETERMINATION

If you bring a claim for benefits under the Plan, the Claims Administrator will respond to your claim within the
following time periods:
 Pre-Service Claim: In the case of a pre-service claim, the Claims Administrator will respond to you within
15 days after receiving the claim. If the Claims Administrator determines an extension is necessary due to
matters beyond the Plan’s control, the Claims Administrator will notify you within the initial 15-day period
that the Claims Administrator needs up to an additional 15 days to review your claim. If such an extension
is because you failed to provide the information necessary to evaluate your claim, the notice of extension
will describe the information you need to provide to the Claims Administrator. You will have at least 45
days from the date you receive the notice to provide the requested information.
 Urgent Care Claim: In the case of an urgent care claim, the Claims Administrator will respond to you as
soon as possible, taking into account the medical exigencies, but not later than 72 hours after receiving the
claim, unless you fail to provide sufficient information to determine whether, or to what extent, benefits
are covered or payable under the Plan. If the Claims Administrator determines it needs additional
information to review your claim, the Claims Administrator will notify you within 24 hours after receiving
the claim and provide you with a description of the additional information it needs to evaluate your claim.
You will have at least 48 hours from the time you receive this notice to provide the requested information.
Once you provide the requested information, the Claims Administrator will evaluate your claim within 48
hours after the earlier of the Claims Administrator’s receiving the requested information, or the end of the
extension period given to you to provide the requested information. There is a special time period for
responding to a request to extend an ongoing course of treatment if the request is an urgent care claim.
For these types of claims, the Claims Administrator must respond to you within 24 hours after the Plan
receives the claim (provided you make the claim at least 24 hours before the ongoing course of treatment
expires).
 Post-Service Claim: In the case of a post-service claim, the Claims Administrator will respond to you within
30 days after receiving the claim. If the Claims Administrator determines an extension is necessary due to
matters beyond the Plan’s control, the Claims Administrator will notify you within the initial 30-day period
that the Claims Administrator needs up to an additional 15 days to review your claim. If such an extension
is necessary because you failed to provide the information necessary to evaluate your claim, the notice of
extension will describe the information you need to provide to the Claims Administrator. You will have at
least 45 days from the date you receive the notice to provide the requested information.
 Concurrent Care Review Claim: For urgent care claims made at least 24 hours before the initially approved
period of time or number of treatments, no later than 24 hours after receiving claim. For all other requests
to extend a concurrent care decision, the decision must be made in the timeframes for pre-service, urgent
care, or post-service claims. If the Plan has already approved an ongoing course of treatment for you and

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contemplates reducing or terminating the treatment, the Claims Administrator will notify you sufficiently
in advance of the reduction or termination of treatment to allow you to appeal the Claims Administrator’s
decision and obtain a determination on review before the treatment is reduced or terminated.
Extensions to the above timeframes for pre-service, post-service, and concurrent care review claims only are
also permitted when the claimant voluntarily agrees to extend the above timeframes. Extensions are not
permitted for urgent care claims.

IF A CLAIM IS DENIED
If the Claims Administrator makes an adverse benefit determination, denying your claim in whole or in part,
the Claims Administrator will provide you with written notice of the adverse determination in a culturally and
linguistically appropriate manner (although initial notice of a denied urgent care claim may be provided to you
orally). This notice will include the following:
 the specific reason or reasons for the denial
 reference to the specific Plan provisions on which the denial is based
 a description of any additional material or information necessary for you to perfect your claim and why the
information is necessary
 a description of the Plan procedures and time limits for appeal of the decision, and the right to obtain
information about those procedures
 a statement that you are entitled to bring a civil action in federal court under Section 502 of ERISA to
pursue your claim for benefits
 if the decision involves scientific or clinical judgment, either an explanation of the scientific or clinical
judgment applying the terms of the Plan to the claimant’s medical circumstances; or a statement that such
explanation will be provided at no charge upon request
 a description of any internal rule, guideline, protocol, or other similar criterion relied upon in making the
initial determination or a statement that such a rule, guideline, protocol, or other criterion was relied upon
in making the appeal determination and that a copy of such rule will be provided to you free of charge at
your request.
For medical claims, the notice will also include information sufficient to identify the claim involved. This
includes:
 for denials involving urgent care, a description of the expedited review process for such claims. This notice
can be provided orally within the timeframe for the expedited process, as long as written notice is
provided no later than 3 days after the oral notice.
 information sufficient to identify the claim involved (including the date of service, the health care provider,
and the claim amount, if applicable)
 a statement that diagnosis and treatment codes (and their meanings) will be provided upon request

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 a description of the Plan’s standard used in denying the claim. For example, a description of the “medical
necessity” standard will be included.
 in addition to the description of the Plan’s internal appeal procedures, a description of the external review
processes
 the availability of, and contact information for, any applicable office of health insurance consumer
assistance or ombudsman to assist enrollees with the internal claims and appeals and external review
processes.

CLAIM APPEALS PROCEDURES

If you receive an adverse benefit determination for your initial claim for benefits, you may appeal the denial
by filing a written request (or an oral request in the case of an urgent care claim) with the Appeals
Administrator within 180 days after you receive the notice denying your initial claim for benefits. If you decide
to appeal a denied claim for benefits, you will be able to submit written comments, documents, records, and
other information relating to your claim for benefits (regardless of whether the information was considered in
your initial claim for benefits) to the Appeals Administrator for review and consideration. You will also be
entitled to receive, upon request and free of charge, access to, and copies of, all documents, records, and
other information relevant to your appeal.
Medical coverage for you and your dependents may continue pending the outcome of an internal appeal. This
means that the Plan will not terminate or reduce any ongoing course of treatment, separate from the services
related to your appeal, without providing advance notice and the opportunity for review. Other eligibility and
plan provisions continue to apply.
The Claims Administrator will forward the appeal request to the appropriate named fiduciary for review. The
review will be conducted by the Claims Administrator (if serving as the reviewer for appeals) or other
appropriate named fiduciary of the Plan. In either case, the reviewer will not be the same individual who made
the initial adverse benefit determination that is the subject of the review, nor the subordinate of such
individual (including any physicians involved in making the decision on appeal if medical judgment is involved).
Where the adverse determination is based in whole or in part on a medical judgment, the reviewer will
consult with an appropriate health care professional. No deference will be afforded to the initial adverse
benefit determination.
You will be able to review your file and present evidence as part of the review. You will have the opportunity
to submit written comments, documents, records, and other information relating to the claim; and you will be
provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and
other information relevant to the claim for benefits. Whether a document, record, or other information is
relevant to the claim will be determined in accordance with the applicable Department of Labor (DOL)
regulations. You also are entitled to the identification of medical or vocational experts whose advice was
obtained on behalf of the Plan in connection with your adverse benefit determination. The review will take
into account all comments, documents, records, and other information submitted by the claimant relating to

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the claim without regard to whether such information was submitted or considered in the initial benefit
determination.
For medical claims, the Claims Administrator will ensure that all claims and appeals are adjudicated in a
manner designed to ensure there is no conflict of interest with regard to the individual making the decision.
The Claims Administrator will ensure the independence and impartiality of the persons involved in making the
decision. Accordingly, decisions regarding hiring, compensation, termination, promotion, or other similar
matters with respect to any individual (such as a claims adjudicator or medical expert) must not be made
based upon the likelihood that the individual will support a denial of benefits. The Claims Administrator will
ensure that health care professionals consulted are not chosen based on the expert’s reputation for outcomes
in contested cases, rather than based on the professional’s qualifications.
For medical claims, prior to making a benefit determination on review, the Claims Administrator must provide
you with any new or additional evidence considered, relied upon, or generated by the Plan (or at the direction
of the Plan) in connection with the medical claim. This evidence will be provided at no cost to you, and will be
given before the determination in order to give you a reasonable opportunity to respond. Prior to issuing a
final internal adverse benefit determination on review based on a new or additional rationale, the rationale
will be provided at no cost to you. It will be given before the determination in order to give you a reasonable
opportunity to respond.
If the Plan fails to strictly adhere to all the requirements of the internal claims and appeals process with
respect to your medical benefit claim, you are deemed to have exhausted the internal claims and appeals
process. In this case, you may seek an external review or pursue legal remedies (as discussed below) without
waiting for further Plan action. However, this will not apply if the error was de minimis, if the error does not
cause harm to the claimant, if the error was due to good cause or to matters beyond the Plan’s control, if it
occurs in context of good faith exchange of information, or if the error does not reflect a pattern or practice of
noncompliance. In that case, you may resubmit your claim for internal review and you may ask the Plan to
explain why the error is minor and why it meets this exception.
Additionally, if your claim is an Urgent Care Claim or a claim requiring an ongoing course of treatment under
the medical benefit plan, you may begin an expedited external review before the Plan’s internal appeals
process has been completed.
The Appeals Administrator will respond to your claim within the following time periods:
 Pre-Service Claim: Within a reasonable time appropriate to the medical circumstances, but not later than
30 days after receiving the appeal;
 Urgent Care Claim: As soon as possible, taking into account medical exigencies, but not later than 72 hours
after receiving the appeal;
 Post-Service Claim: Within a reasonable period, but not later than 60 days after receiving the appeal and
 Concurrent Care Review Claim: To reduce or terminate an initially approved course of treatment, before
the proposed reduction or termination takes place. For all other requests for review concerning claims to

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extend a concurrent care decision, the decision must be made in the timeframes for pre-service, urgent
care, or post-service appeals.

NOTICE OF APPEAL DETERMINATION

If the Appeals Administrator denies your claim (in whole or in part), the Appeals Administrator will provide you
with written notice in a culturally and linguistically appropriate manner of the denial (although initial notice of
a denied urgent care claim may be provided to you orally or by fax or other similarly expeditious means of
communication). This notice will include the following:
 the specific reason or reasons for the denial
 a reference to the specific Plan provisions on which the denial is based
 if the decision involves scientific or clinical judgment, either an explanation of the scientific or clinical
judgment applying the terms of the Plan to your medical circumstances; or a statement that such
explanation will be provided at no charge upon request
 a description of any internal rule, guideline, protocol, or other similar criterion relied upon in making the
initial determination or a statement that such a rule, guideline, protocol, or other criterion was relied upon
in making the appeal determination and that a copy of such rule will be provided to you free of charge at
your request
 a statement of entitlement to documents — a statement that you are entitled to receive, upon request
and free of charge, access to and copies of, all documents, records and other information relevant to your
claim and/or appeal for benefits
 a statement that you are entitled to bring a civil action in federal court under Section 502 of ERISA to
pursue your claim for benefits
 a description of voluntary appeals procedure under the Plan, if any, and your right to obtain additional
information upon request about such procedures.
For medical claims, the notice will also include information sufficient to identify the claim involved. This
includes:
 for denials involving urgent care, a description of the expedited review process for such claims. This notice
can be provided orally within the timeframe for the expedited process, as long as written notice is
provided no later than 3 days after the oral notice.
 information sufficient to identify the claim involved (including the date of service, the health care provider,
and the claim amount, if applicable)
 a statement that diagnosis and treatment codes (and their meanings) will be provided upon request
 a description of the Plan’s standard used in denying the claim. For example, a description of the “medical
necessity” standard will be included
 in addition to the description of the Plan’s internal appeal procedures, a description of the external review
processes

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 the availability of, and contact information for, any applicable office of health insurance consumer
assistance or ombudsman to assist enrollees with the internal claims and appeals and external review
processes.
During the appeal process, you are entitled to receive:
 an opportunity to present evidence and testimony,
 reasonable access to, and copies of, all documents, records and other information relevant to the claim for
benefits, and
 any new or additional rationale or evidence the Plan is using as a basis for an adverse benefit
determination on appeal, as well as a reasonable opportunity to respond before the due date for the
benefit decision on appeal.
Unless the right to an external review applies under the medical benefit plan, all decisions are final and
binding unless determined to be arbitrary and capricious by a court of competent jurisdiction.

IF AN APPEAL IS DENIED
If the Appeals Administrator denies your appeal, you have the right to an External Review. Your request for a
Standard External Review must be filed within four months after your receiving the benefits denial notice.
You may request an Expedited External Review if:
 the expedited internal appeal timeframe would seriously jeopardize your life or health or ability to regain
maximum function and you have filed an expedited internal appeal; or
 the request for External Review concerns a final internal benefits denial involving (a) a medical condition
where the Standard External Review timeframe would seriously jeopardize your life or health or ability to
regain maximum function; or (b) the request for External Review concerns a final internal benefits denial
involving an admission, availability of care, continued stay, or health care item or service for which you
received emergency services, but has not yet been discharged.
If you requested a Standard External Review, the Plan must render the preliminary review determination no
later than five business days after receiving your External Review request, and notify you within one business
day of completing such review. The preliminary review must determine whether:
 you are/were covered under the Plan when the healthcare item or service was requested (for retroactive
reviews, you were covered when the healthcare item or service was provided),
 the benefit denial does not relate to your failure to meet the Plan’s eligibility requirements,
 you have exhausted the Plan’s internal appeals process, and
 you have provided all the information and forms to process the External Review.
If you requested an Expedited External Review, the Plan must “immediately” assess whether the request
meets the above reviewability requirements and notify you of its decision.

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You may supplement an incomplete request by the end of the remainder of the four-month filing period or, if
expired, 48 hours after receiving the preliminary review determination notice.

Referral to an Independent Review Organization (IRO)

The Plan must refer reviews to an Independent Review Organization (IRO) by contracting with at least three
IROs and rotating claims assignments among them, or by incorporating other independent, unbiased methods
for selection of IROs, such as random selection, to ensure independence. The Plan may comply with a state’s
external review process if the state’s process is made available for self-insured group health plans and satisfies
the requirements of DOL Technical Release 2010-10.
The IRO will consult medical and legal experts to make coverage determinations, as appropriate. The Plan
must provide the IRO with all documents and information considered in making the benefit denial within 5
business days after the assignment date. If the Plan fails to timely provide the information, the IRO may
terminate the external review, reverse the denial, and notify the claimant within one business day.
The IRO must provide the Plan with information received from the claimant within one business day and the
Plan may reconsider the denial. If the Plan, upon reconsideration, decides to reverse the benefits denial, the
Plan must provide written notice to the claimant and the IRO within one business day of reconsideration. The
IRO may then terminate the External Review process.

IRO Decision and Notification to Claimant of Final External Review Decision

In the case of a Standard External Review, the IRO must render its decision and notify you within 45 days after
receiving the External Review request.
In the case of an Expedited External Review, the IRO must render its decision and notify you “as expeditiously
as the claimant’s medical condition or circumstances require,” but no later than 72 hours after receiving the
expedited External Review request. Notice may be provided orally, but written notice must be furnished no
later than 48 hours after the oral notice. The decision must also include a statement that judicial review may
be available to you, as well as a phone number and contact information for the applicable offices of health
insurance consumer assistance or ombudsman.
The IRO final decision is binding upon the Plan. However, binding nature is not intended to trump access to
the courts for you, the Plan, or the insurer.

NON-HEALTH CLAIM FILING AND APPEAL PROCEDURES

In the case of a claim not involving health benefits (e.g., life, AD&D, supplemental AD&D insurance, business
travel accident, and Dependent Care FSA), initial claims for benefits under the Plan should be made by you or
your authorized representative in writing to the Claims Administrator.

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NOTICE OF CLAIM DETERMINATION

The Claims Administrator will respond to you within 90 days after receiving the claim. For claims not involving
disability benefits, if the Claims Administrator determines an extension is necessary due to matters beyond
the Plan’s control, the Claims Administrator will notify you within the initial 90-day period that up to an
additional 90 days is needed to review your claim.

IF A CLAIM IS DENIED
If the Claims Administrator denies your claim (in whole or in part), the Claims Administrator will provide you
with written notice of the denial. This notice will include the following:
 the specific reason or reasons for the denial;
 reference to the specific Plan provisions on which the denial is based;
 a description of any additional material or information necessary for you to perfect your claim and an
explanation as to why the information is necessary;
 a description of the Plan’s appeals procedures and the time limits applicable for such procedures; and
 a statement that you are eligible to bring a civil action in federal court under Section 502 of ERISA to
pursue your claim for benefits.

CLAIMS APPEALS PROCEDURES

If the Claims Administrator denies your initial claim for benefits, you may appeal the denial by filing a written
request with the Appeals Administrator within 60 days after you receive the notice denying your initial claim
for benefits. If you decide to appeal a denied claim for benefits, you will be able to submit written comments,
documents, records, and other information relating to your claim for benefits (regardless of whether the
information was considered in your initial claim for benefits) to the Appeals Administrator for review and
consideration. You will also be entitled to receive, upon request and free of charge, access to and copies of all
documents, records and other information relevant to your appeal.

NOTICE OF APPEAL DETERMINATION

If you bring a claim for benefits under the Plan, the Claims Administrator will respond to you within 60 days
after receiving the claim. If the Claims Administrator determines an extension is necessary due to matters
beyond the Plan’s control,
The Claims Administrator will notify you within the initial 60-day period that up to an additional 60 days is
needed to review your claim.

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IF AN APPEAL IS DENIED
If the Appeals Administrator denies your claim (in whole or in part), the Appeals Administrator will provide you
with written notice of the denial. This notice will include the following:
 the specific reason or reasons for the denial;
 reference to the specific Plan provisions on which the denial is based;
 a statement that you are entitled to receive, upon request and free of charge, access to and copies of, all
documents, records and other information relevant to your claim and/or appeal for benefits;
 a statement that you are entitled to bring a civil action in federal court under Section 502 of ERISA to
pursue your claim for benefits; and
 a description of voluntary appeals procedure under the Plan, if any, and your right to obtain additional
information upon request about such procedures.
All decisions of the Appeals Administrator are final and binding unless determined to be arbitrary and
capricious by a court of competent jurisdiction. If you challenge the decision of the Appeals Administrator, a
review by a court of law will be limited to the facts, evidence, and issues presented during the claims
procedure set forth above. The appeal process described herein must be exhausted before you can pursue the
claim in federal court. Facts and evidence that become known to you after having exhausted the appeals
procedure may be submitted for reconsideration of the appeal in accordance with the time limits established
above. Issues not raised during the appeal will be deemed waived.

STATEMENT OF ERISA RIGHTS

Many of the plans that make up the UHS benefits program are subject to the requirements of the Employee
Retirement Income Security Act (ERISA). The goal of ERISA is to safeguard the interest of participants and
beneficiaries in employee benefit plans. You are entitled to rights and protections under ERISA if you
participate in any of the benefit plans listed under “Type of Plan.”
ERISA provides that all Plan participants shall be entitled to:

Receive Information About Your Plan and Benefits

 Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as
worksites and union halls, all documents governing the Plan, including insurance contracts and collective
bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the
U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefit Security
Administration.
 Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of
the Plan, including insurance contracts and collective bargaining agreements, and copies of the latest
annual report (Form 5500 Series) and updated SPD. The Plan Administrator may make a reasonable charge
for the copies.

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 Receive a summary of the Plan’s annual financial report, if any is required to be prepared by ERISA. The
Plan Administrator is required by law to furnish each participant with a copy of this summary annual
report.

Continue Group Health Plan Coverage

 Continue healthcare coverage for yourself, spouse, or dependents if there is a loss of coverage under the
Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review
this SPD and the documents governing the Plan for the rules governing your COBRA continuation coverage
rights.

Prudent Actions by Plan Fiduciaries

In addition to certain rights for Plan participants, ERISA imposes duties upon the people who are responsible
for the operation of the Plan. The people who operate your Plan, called “fiduciaries” of the Plan, have a duty
to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including
your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way
to prevent you from obtaining a pension or welfare benefit or exercising your rights under ERISA.

Enforce Your Rights

If your claim for a pension or welfare benefit is denied or ignored, in whole or in part, you have a right to know
why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any
denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of
Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file
suit in a federal court. In such a case, the court may require the Plan Administrator to provide the materials
and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of
reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in
whole or in part, you may file suit in a state or federal court. In addition, if you disagree with the Plan’s
decision or lack thereof concerning the qualified status of a domestic relations order or a medical child
support order, you may file suit in federal court. If it should happen that Plan fiduciaries misuse the Plan’s
money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S.
Department of Labor or you may file suit in a federal court. The court will decide who should pay court costs
and legal fees. If you are successful, the court may order the person you have sued to pay these costs and
fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is
frivolous.

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Assistance with Your Questions

If you have any questions about your Plan, you should contact the Plan Administrator. If you have any
questions about this statement or about your rights under ERISA, or if you need assistance in obtaining
documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits
Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of
Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor,
200 Constitution Avenue, N.W., Washington, DC 20210. 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 (866) 444-3272.

SCHEDULE OF INSURANCE CARRIERS OR CLAIMS ADMINISTRATORS

Type of Plan Agents Contract/ Plan No.
Policy No.
The following benefits are self-insured by UHS. This means that these benefits are paid directly out of the general assets of UHS
and are not guaranteed under a contract of insurance. UHS has engaged the services of the following third-party administrators
who are responsible for processing claims for these certain self-insured benefits. UHS, however, is the Plan fiduciary with
authority to make final claims determinations on appeal.
Medical Plans United HealthCare Services, Inc. 709955 or 512
P.O. Box 740800 745139
Atlanta, GA 30374-0800
(800) 440-5982
BlueCross BlueShield of Tennessee 82096 512
1 Cameron Hill Circle
Chattanooga, TN 37402
(888) 294-2839
Aetna, Inc. 868613 512
151 Farmington Avenue
Hartford, CT 06156
(866) 435-7174
Open Access Aetna Select Aetna, Inc. 868616 512
151 Farmington Avenue
Hartford, CT 06156
(866) 435-7174
Blue Cross Blue Shield of TN- BlueCross BlueShield of Tennessee 82096 512
EPO Plan 1 Cameron Hill Circle
Chattanooga, TN 37402
(888) 294-2839
Prescription Drug Feature CVS Caremark Corporation RX7517 512
(applicable to the medical One CVS Drive
plans listed above) Woonsocket, RI 02895
(401)765-1500

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Type of Plan Agents Contract/ Plan No.

Policy No.
UHS Flexible Spending Optum Financial n/a 512
Accounts and Health Savings 307 International Circle
Accounts Suite 200
Hunt Valley, MD 21030
(844) 400-5720
Dental Plan Delta Dental PA12316 512
P.O. Box 2105
Mechanicsburg, PA 17055-6999
(800) 932-0783
The following benefits are insured through contracts with insurance companies who administer claims for these benefits and are
solely responsible for providing the benefits. The insurance companies are also the Plan fiduciaries with sole authority to make
final claims determinations on appeal.
Accident Insurance Reliastar Life Insurance Company (a member of Voya family of 71157- 512
companies) 8CAC2
20 Washington Ave. South
Minneapolis, MN 55401
(877)236-7564
Critical Illness Insurance Reliastar Life Insurance Company (a member of Voya family of 71157- 512
companies) 8CC12
20 Washington Ave. South
Minneapolis, MN 55401
(877)236-7564
Wellness Benefit Voya 0071157-8 512
P.O. Box 320
Minneapolis, MN 55440
(877) 236-7564
Voya Travel Assistance International Medical Group 71157-8 512
(317) 659-5841
Vision Plan Vision Service Plan 30027669 512
P.O. Box 997105
Sacramento, CA 95899-7105
(800) 877-7195
Life Insurance Hartford Life & Accident Insurance Co. GL- 34226 512
Dependent Life Insurance One Hartford Plaza GL- 34226 512
Hartford, CT 06155
AD&D Insurance (800) 563-1124 ADD-S07317 512
Supplemental AD&D ADD-S07317 512
Insurance
Business Travel Accident GTA-101295 512
Long-Term Disability Hartford Life & Accident Insurance Co. GLT-675157 512
One Hartford Plaza
Short-Term Disability GRH-677087 512
Hartford, CT 06155
(800) 563-1124

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Type of Plan Agents Contract/ Plan No.

Policy No.
Various HMOs and Refer to each HMO or Alternative Health Plan’s certificate, handbook, or 512
Alternative Health Plans informational packet.
Additional Information
Retirement Savings Plan Trustee: Fidelity Management Trust Co. 90266 001
82 Devonshire Street
Boston, MA 02109
(800) 835-5092

EMPLOYEE PRIVACY NOTICE

This notice describes how medical information about you may be used and disclosed and how you can get
access to this information. Please review it carefully.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires health plans to notify plan
participants and beneficiaries about its policies and practices to protect the confidentiality of their health
information. This document is intended to satisfy HIPAA’s notice requirement with respect to all health
information created, received, or maintained by the Universal Health Services, Inc. Welfare Benefit Plan, as
sponsored by Universal Health Service, Inc. and its subsidiaries (the Company).
The Plan needs to create, receive, and maintain records that contain health information about you to
administer the Plan and provide you with health benefits. This notice describes the Plan’s health information
privacy policy with respect to your benefits under the following plans:
 UHS Medical Plans
 Prescription Drug Feature (as provided by CVS Caremark to certain medical options)
 UHS Dental Plan
 Healthcare Flexible Spending Accounts.
With respect to fully insured health plans provided by UHS (e.g., various HMOs and Vision Plan), you will
receive or may obtain a copy of each carrier’s Employee Privacy Notice directly from the carrier.
This notice tells you the ways the Plan may use and disclose health information about you and describes your
rights and the obligations the Plan has regarding the use and disclosure of your health information. However,
it does not address the health information policies or practices of your healthcare providers.

COMMUNICATION WITH YOU

HIPAA may change or influence the manner in which the UHS Benefits Service Center or the UHS Corporate
Benefits Department assist you with matters involving personal health information. When you call or email,
we may need to confirm, with certainty, your identity (by your providing us with your Social Security number
or other personal identification information) before proceeding with the problem resolution process. Certain

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individuals that you ask to assist you (e.g., a supervisor or certain individuals outside of the UHS Corporate
Benefits Department) may not be able to assist you without your written authorization. This assures that your
personal health information does not fall into the hands of someone not entitled to that information. Your
understanding in helping us meet our responsibility under HIPAA and to protect your privacy is appreciated.

UHS’ PLEDGE REGARDING HEALTH INFORMATION PRIVACY

The privacy policy and practices of the Plan protects confidential health information that identifies you or
could be used to identify you and relates to a physical or mental health condition or the payment of your
healthcare expenses. This individually identifiable health information is known as “protected health
information” (PHI). Your PHI will not be used or disclosed without a written authorization from you, except as
described in this notice or as otherwise permitted by federal and state health information privacy laws.

PRIVACY OBLIGATIONS OF THE PLAN

The Plan is required by law to:
 make sure that health information that identifies you is kept private,
 give you this notice of the Plan’s legal duties and privacy practices with respect to health information
about you, and
 follow the terms of the notice currently in effect.

HOW THE PLAN MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT
YOU
The following are the different ways the Plan may use and disclose your PHI:
 For Treatment. The Plan may disclose your PHI to a healthcare provider who renders treatment on your
behalf. For example, the Plan may disclose to a treating surgeon the name of your treating primary care
physician so that the surgeon may ask for medical history from the treating physician.
 For Payment. The Plan may use and disclose your PHI so claims may be paid according to the Plan’s terms.
For example, the Plan may tell a physician’s office whether you are eligible for coverage or what
percentage of the bill will be paid by the Plan.
 For Healthcare Operations. The Plan may use and disclose your PHI to enable it to operate or operate
more efficiently or make certain all of the Plan’s participants receive their health benefits. For example,
the Plan may use your PHI for case management, healthcare costs studies, compliance reviews, audits,
actuarial studies, and/or fraud and abuse detection.
 To the Company. The Plan may disclose your PHI to designated Company representatives so they can carry
out their Plan-related administrative functions. Such disclosures will be made only to the Company’s
Director of Employee Benefits and/or members of the UHS Corporate Benefits Department to the extent
necessary to carry out Plan duties and functions. These individuals will protect the privacy of your health

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information and ensure it is used only as described in this notice as permitted by law. Unless authorized by
you in writing, your health information: (1) may not be disclosed by the Plan to any other Company
employee or department and (2) will not be used by the Company for any employment-related actions and
decisions or in connection with any other employee benefit plan sponsored by the Company.
 To a Business Associate. Certain services are provided to the Plan by third-party administrators known as
“business associates.” For example, the Plan may transmit your health information via a secure electronic
file maintained by the Plan’s business associate so your claim may be paid. In so doing, the Plan will
disclose your PHI to its business associate so it can perform its claims payment function. However, the Plan
will require its business associates, through contract, to appropriately safeguard your health information.
Some of UHS’ business associates include Aetna, Inc., United Healthcare, BlueCross BlueShield of
Tennessee, and Optum Financial for Flexible Spending Account administration; CVS Caremark for
prescription drug claim administration and Delta Dental for dental claim administration. This list of
business associates may be incomplete and may change from time to time at the discretion of the Plan
Sponsor and is not inclusive of all services contracted through our business associate agreements.
 Treatment Alternatives and Health-Related Benefits and Services. The Plan may use and disclose your PHI
to tell you of possible health-related benefits or services, treatment options, or alternatives that may be of
interest to you.
 Individuals Involved in Your Care or Payment of Your Care. The Plan may disclose PHI to a close friend or
family member involved in, or who helps pay for, your healthcare. This will be done with your advance
approval whenever possible.
 As Required by Law. The Plan will disclose your PHI when required to do so by federal, state, or local law,
including those that require the reporting of certain types of wounds or physical injuries.

SPECIAL USE AND DISCLOSURE SITUATIONS

 Lawsuits and Disputes. If you become involved in a lawsuit or other legal action, the Plan may disclose your
PHI in response to a court or administrative order, subpoena, warrant, discovery request, or other lawful
due process.
 Law Enforcement. The Plan may release your PHI if asked to do so by a law enforcement official.
 Workers’ compensation. The Plan may disclose your PHI to the extent authorized by, and to the extent
necessary to, comply with Workers’ Compensation laws or other similar programs.
 Military and Veterans. If you are or become a member of the U.S. armed forces, the Plan may release
medical information about you as deemed necessary by military command authorities.
 To Avert Serious Threat to Health or Safety. The Plan may use and disclose your PHI when necessary to
prevent a serious threat to your health and safety, or the health and safety of the public or another
person.
 Public Health Risks. The Plan may disclose health information about you for public health activities.
 Health Oversight Activities. The Plan may disclose your PHI to a health oversight agency for audits,
investigations, inspections, and licensure necessary for the government to monitor the healthcare system
and government programs.

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 Research. Under certain circumstances, the Plan may use and disclose your PHI for medical research
purposes.
 National Security, Intelligence Activities, and Protective Services. The Plan may release your PHI to
authorized federal officials (1) for intelligence, counterintelligence, and other national security activities
authorized by law and (2) to enable them to provide protection to the members of the U.S. government or
foreign heads of state, or to conduct special investigations.
 Organ and Tissue Donation. If you are a registered organ donor, the Plan may release medical information
to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ
bank to facilitate organ or tissue donation and transplantation.
 Coroners, Medical Examiners, and Funeral Directors. The Plan may release your PHI to a coroner, medical
examiner, or funeral director, as necessary, to carry out his or her duties.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

Your rights regarding the health information the Plan maintains about you are as follows:
 Right to Inspect and Copy. You have the right to inspect and copy your PHI, excluding psychotherapy notes.
 Right to Amend. If you feel that health information the Plan has about you is incorrect or incomplete, you
may ask the Plan to amend it. This includes records created by the Plan, not PHI received or maintained by
other entities.
 Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures. This is a
list of disclosures of your PHI that the Plan has made to others, except for those necessary to carry out
healthcare treatment, payment, or operations.
 Right to Request Restrictions. You have the right to request a restriction on the health information the
Plan uses or discloses about you for treatment, payment, or healthcare operations. You also have the right
to limit disclosures to someone who is involved in your care or the payment of your care.
 Right to Request Confidential Communication. You have the right to request that the Plan communicate
with you about health matters in a certain way or at a certain location.
Please direct, to UHS, requests to inspect, copy, or amend health information maintained by the Plan or to
request an accounting of disclosures made, or to request restrictions on the disclosures of confidential
communications. The Plan may deny your request to the extent permissible under HIPAA. Generally, if you are
denied, you may request a review of the denial. In response to this request, UHS may need to contact carriers
and claims administrators that may hold your information.

CHANGES TO THIS NOTICE

The Plan reserves the right to change this notice at any time and to make the revised or changed notice
effective for health information the Plan already has about you, as well as any information the Plan receives in
the future.

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COMPLAINTS
If you believe your privacy rights under this policy have been violated, you may file a written complaint with
UHS at the address listed below. Alternatively, you may complain to the Company’s Privacy Officer at the
Company’s corporate address or to the Secretary of the U.S. Department of Health and Human Services,
generally within 180 days of when the act or omission complained of occurred. You will not be penalized or
retaliated against for filing a complaint.

OTHER USES AND DISCLOSURES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this notice or by the laws that apply to the
Plan will be made only with your written authorization. If you authorize the Plan to use or disclose your PHI,
you may revoke the authorization, in writing, at any time. If you revoke your authorization, the Plan will no
longer use or disclose your PHI for the reasons covered by your written authorization; however, the Plan will
not reverse any uses or disclosures already made in reliance on your prior authorization.

CONTACT INFORMATION
If you have any questions about this notice, please contact:
Universal Health Services, Inc.
367 S. Gulph Road
P.O. Box 61558
King of Prussia, PA 19406-0958
Attention: UHS Benefits Department
Notice Effective date: April 15, 2006

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