SPD Ra Spd2011

Rite Aid Corporation
Master Welfare Benefit Plan

Summary Plan Description
Effective July 1, 2011

RIT SPD (11)
Welcome
This booklet is designed to inform you about your medical, dental and vision care coverage, group-term life and long-term disability insurance, and other benefits provided to you by Rite Aid Corporation through the Rite Aid Corporation Master Welfare Benefit Plan (the Plan). The booklet provides only a summary of the benefits made available to eligible associates and their eligible dependents. Benefits provided under the terms of a collective bargaining agreement may vary from the benefits and eligibility requirements described in this booklet. The rights of any person to participate in the Plan, or to receive any benefits under the Plan, are determined solely by the detailed schedules of benefits, and applicable insurance certificates, by the governing Plan document and, if applicable, by the collective bargaining agreement pertaining to the person. You may receive a copy of any of these documents at no charge upon request to the Rite Aid Benefits Service Center by calling 800-343-1390. Documents are also available online at My Benefits Center accessible via rNation.riteaid.com or www.riteaidbenefits.com. The booklet does not constitute a contract of any sort, nor does it represent any obligation by Rite Aid to maintain any particular benefit program or policy. Subject to any applicable collective bargaining considerations, any of the benefits provided under the Plan may be modified, replaced or terminated by Rite Aid at any time.
TABLE OF CONTENTS
ELIGIBILITY ENROLLMENT SUMMARY OF BENEFITS CONTINUATION OF COVERAGE (COBRA) FLEXIBLE SPENDING ACCOUNTS CLAIM PROCEDURES: MEDICAL PLANS CLAIM PROCEDURES: DENTAL PLANS NOTICE OF PRIVACY PRACTICES STATEMENT OF ERISA RIGHTS INFORMATION ABOUT THE PLAN APPENDIX 1 3 8 11 15 18 34 37 42 44 45
Eligibility
Unless indicated elsewhere in this booklet or in a governing document, a person will be eligible to participate in a benefit program made available under the Plan pursuant to the rules prescribed below.
Associates
For All Benefits Except Long Term Disability All associates are eligible for coverage under the Plan effective as of the first day of the month following the completion of two consecutive months of employment. In order to become eligible, all associates must be compensated for a minimum of 30 hours per week on average. Long Term Disability Associates are eligible for long term disability (LTD) benefits. Upon enrollment, coverage under the LTD program will commence on the first day of the month following the associates completion of six consecutive months of employment. No evidence of good health will be required if an associate enrolls when he/she first becomes eligible. If an associate does not enroll when he/she first becomes eligible for this benefit, evidence of good health will be required prior to the benefit becoming effective. An associate who is a member of a collective bargaining unit is not eligible to participate in a benefit program unless the governing collective bargaining agreement expressly provides for such coverage. If the collective bargaining agreement provides for coverage, then the associate will be eligible for coverage as prescribed under the collective bargaining agreement.
Dependents
In general, the individuals described below can be deemed to be your dependents and are eligible to be enrolled for medical, dental and vision care coverage, and for certain other benefits. Spouse Your legal spouse, as defined by the IRS. Same Sex Domestic Partner Your same sex domestic partner provided the associate and their domestic partner meet all the criteria below: 1. 2. 3. You are both of the same sex; You have resided together for at least one year, and intend to do so indefinitely; You are not related by blood to a degree of closeness that would prohibit marriage; You are mutually responsible for basic living expenses; You are both at least age 18, and are mentally competent;
4. 5.
7/1/11 Rite Aid Corporation MWP
6.
Neither of you is married to, or involved in another domestic partnership with, anyone else; and An "Affidavit of Domestic Partnership" is submitted and approved by the Benefits Department, or its designee.
7.
Upon request, an associate must provide documents establishing that a person enrolled under the Plan as a same sex domestic partner meets the eligibility criteria set forth above. If the associate does not provide the requested documentation in a timely manner, the domestic partner's coverage will not be granted. The associate may further be required to reimburse the Plan for any expenditures made on behalf of the ineligible domestic partner, including, but not limited to, premiums, medical claims, administrative charges and attorneys' fees. Child Your children up to age 26, regardless of their student or tax dependent status. Children who may be eligible for coverage as your dependent include the following: Your natural child; Your stepchild; Your legally adopted child or a child placed for adoption; or
A grandchild is eligible for coverage only if adopted by an associate or by an associate's eligible spouse or same sex domestic partner.
Child of Same Sex Domestic Partner (Domestic Dependent) Children of your same sex domestic partner up to age 26, regardless of their student or tax dependent status. A child of same sex domestic partner that may be eligible for coverage as your dependent include the following: Your same sex domestic partners natural child; Your same sex domestic partners legally adopted child or a child placed for adoption; A grandchild is eligible for coverage only if adopted by your same sex domestic partner.
Legal Guardianship Any other unmarried child who depends solely on you for support and regularly and permanently resides with you in a parent-child relationship and for whom you have permanent legal custody. A person may not be eligible for coverage under the Plan as both an associate and as a dependent of another associate. In addition, no person may be eligible as a dependent of more than one enrolled associate.
Qualified Medical Child Support Orders

The Plan will comply with the terms of any Qualified Medical Child Support Order. This is a child support order, judgment or decree (including a court-ordered marital settlement agreement) requiring a medical or other group health plan to allow you to enroll the child for medical coverage. A court order must meet certain legal requirements to be a Qualified Medical Child Support Order. The Plan Administrator has the sole authority to determine whether those legal requirements have been met. If these requirements have been met, the group health plan must provide the coverage required by the order. However, you will be required to make the same
contributions for the coverage of the child that is otherwise payable for the coverage of a dependent. You will be notified if the Plan Administrator receives a Qualified Medical Child Support Order relating to you. A copy of the Plan's Qualified Medical Child Support Order review procedures is available via My Benefits Center accessible online via rNation.riteaid.com or www.riteaidbenefits.com, or you may request a copy by calling the Rite Aid Benefits Service Center 1-800-343-1390.
Enrollment
Timing of Enrollment
An associate and an eligible dependent must enroll within the first 30 days following the date of initial eligibility in order to qualify for coverage. Under the Plan, an associate or dependent that does not enroll within 30 days of initial eligibility for coverage must generally wait until the next open enrollment period to do so. However, an individual will not have to wait for the next open enrollment period in either of the following situations: The individual qualifies for either of the special enrollment period provisions discussed below; or The individual is affected by a qualifying life event, as also discussed below.
When Coverage Begins

Your coverage begins on your eligibility date if you applied for enrollment before that date. If you apply later but within 30 days after the date that you become eligible, your coverage will also become effective on that eligibility date. Rite Aid has an annual open enrollment period during which you may enroll for benefits. Your coverage will begin on the effective date following the open enrollment period, which typically is July 1 of each year. You may not enroll in or change your benefit elections outside of the annual open enrollment period unless you experience a qualifying life event. If you become eligible for coverage due to a work-related event, such as a change in job status, your coverage will begin the first day of the month following the date of the change in job status.
Special Enrollment Period

If you decline health coverage under the Plan for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, including Medicaid or SCHIP (State Childrens Health Insurance Program), you may be eligible to enroll yourself and your dependents for group health coverage under this Plan before the next open enrollment period if you or your dependents lose eligibility for that other coverage. You may also enroll if you or your dependent becomes eligible for a premium assistance subsidy through Medicaid or SCHIP. You may also then elect to change to another group health program available to you under the Plan, or change group health benefit options. You must request group health enrollment in this Plan or other change within 60 days of the date coverage under the other health plan ends. Otherwise, you must wait until the next open enrollment period to enroll or change your benefit options. The effective date of the new coverage will be the first of the month following the date of the loss of coverage. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents, or change benefit options before the next open enrollment period. However, you must request enrollment within 60 days after the marriage, new domestic partnership, birth, adoption, or placement for adoption. Please do not wait to call until you have the babys social security number. The effective date of the enrollment or change will be the date of birth, adoption, placement for adoption or marriage. The coverage of a new domestic partner will become effective as of the first of the month following the date the enrollment request is received and approved by the Benefits Department. If you have individual coverage, you must change to associate plus child or family coverage to add a dependent.
To request special enrollment or obtain more information, contact the Rite Aid Benefits Service Center, at 1-800-343-1390.
Qualifying Life Events

A qualifying life event is an event that will allow you to enroll in a benefit program under the Plan, or to make changes to your benefit options (including elections made under the Flexible Spending Account program) during the middle of a plan year (i.e., outside of the open enrollment period). In order to make the mid-year election, the qualifying life event must have an impact upon the affected persons eligibility under the benefit program. The qualifying life events that may allow you to change your election for a plan year are as follows: An event that changes your legal marital status, including marriage, death of your spouse, divorce, legal separation or annulment; An event that changes the number of your dependents, including the birth, adoption, placement for adoption or death of a dependent; The commencement or termination of employment; The commencement of or return from an unpaid leave of absence; An event that causes a dependent to satisfy or cease to satisfy the requirements for coverage under a benefit plan due to attainment of age, student status or similar circumstances; A change in work location or residence; A judgment, decree or order resulting from a divorce, legal separation, annulment or change in legal custody that obligates you to provide group health coverage for your child, or which releases you from such an obligation; or Enrollment in Medicare (Part A or Part B).
To request enrollment or a benefit election change upon the occurrence of a qualifying life event, go to My Benefits Center via rNation.riteaid.com or www.riteaidbenefits.com. Or, you can contact the Rite Aid Benefits Service Center by calling 1-800-343-1390. The request must be made within 60 days of the event.
Maintaining Coverage
In order to maintain coverage under the Plan, you must work an average of 30 hours per week. Each month, Rite Aid will calculate your average weekly hours over a 14-week period. Hours included are those for which you are compensated in pay periods that end within the 14-week monitoring period. If you have been paid for an average of 30 hours per week during the monitoring period, your coverage will remain in effect for the 14-week period which begins on the first day of the next calendar month. If you have not been paid for sufficient hours and your average hours are less than the required average your coverage will end as of the last day of the month. A COBRA continuation packet will then be sent to your home address. If you lose coverage due to insufficient hours worked, but subsequently work enough hours during a 14-week monitoring period, you may again be eligible to enroll as of the first of the month following the monitoring period in which you again work sufficient hours.
The dates for the monthly monitoring process this plan year will be:
Monthly Monitoring Period 3/19/11 to 6/18/11 4/23/11 to 7/23/11 5/21/11 to 8/20/11 6/18/11 to 9/17/11 7/23/11 to 10/22/11 8/20/11 to 11/19/11 9/17/11 to 12/17/11 10/22/11 to 1/21/12 11/19/11 to 2/18/12 12/17/11 to 3/17/12 1/21/12 to 4/21/12
Effective Enrollment Date 8/1/11 9/1/11 10/1/11 11/1/11 12/1/11 1/1/12 2/1/12 3/1/12 4/1/12 5/1/12 6/1/12
If you are covered by a collective bargaining agreement, the period over which your hours are averaged, and the weekly average hours, may differ.
Termination of Coverage
Coverage under the Plan, or under any particular benefit program, will cease at the end of the month that any of the following occurs: Your employment is terminated; You fail to meet the eligibility requirements of the Plan or program; You fail to make the required contributions; You are on layoff or you have exhausted your 180 days of medical leave; There is a discovery of fraud or intentional misrepresentation of a material fact by you; or The associates death.
A spouses or same sex domestic partners coverage under the Plan or benefit program will cease at the end of the month upon any of the following applicable events: You become divorced or legally separated from your spouse; or Any of the criteria of domestic partnership is no longer met for your domestic partner; or The associates death (except as provided below).
A childs coverage under the Plan or benefit program will cease at the end of the month upon either of the following applicable events: The child ceases to be a dependent under the applicable eligibility rules; or The associates death (except as provided below).
In the event of the associates death, a spouse, same sex domestic partner or childs coverage under medical, dental or vision will cease at the end of the month following 60 days from the date of the associates death. In all cases, the termination of coverage occurs automatically and without notice. You must notify the Rite Aid Benefits Service Center within 60 days if your dependent becomes ineligible, or if you become divorced. If you fail to notify the Rite Aid Benefits Service Center within 60 days, you may be required to repay the Plan for any claims paid during the time your dependent was not eligible for coverage.
If coverage has terminated due to your termination of employment, and you are reemployed in a full-time position, your benefit elections will be reinstated if your coverage has been terminated for less than 30 days.
Required Premiums
Associates are required to contribute toward the cost of coverage under the Plan. If your spouse or same sex domestic partner is enrolled in any Rite Aid medical plan and has medical coverage available through his or her employer, a $75 surcharge will be added to your monthly contribution for medical coverage. You may go to My Benefits Center, accessible via rNation.riteaid.com or www.riteaidbenefits.com, at any time to update whether the spousal surcharge applies to you. If either you or your covered spouse or same sex domestic partner, or both, are tobacco users, a $40 surcharge will be added to your monthly contribution for medical coverage. Once you and your spouse or same sex domestic partner can certify online (either through rNation.riteaid.com or www.riteaidbenefits.com) that you have been tobacco free for 60 days, the $40 surcharge will be removed. If it is unreasonably difficult due to a medical condition or if it is medically inadvisable for you to attempt to quit tobacco use, you may become eligible for the non-tobacco user contribution rate if your doctor completes the Statement of Physician to this effect. You may be required to complete a smoking cessation program as an alternative. Go to My Benefits Center, accessible via rNation.riteaid.com, at www.riteaidbenefits.com to download the Statement of Physician. Or, you can call the Rite Aid Benefits Service Center at 800-343-1390 to request that a copy be mailed to you. Contributions to the Plan are also required by COBRA eligible individuals who elect to continue coverage under a group health plan. Associates will be provided information regarding the applicable premium costs each year during the open enrollment period. The information can also be obtained at any time via My Benefits Center at rNation.riteaid.com, at www.riteaidbenefits.com, or by calling the Rite Aid Benefits Service Center at 1-800-343-1390. Rite Aid may terminate the coverage of an associate and an associates dependents, and may recover any benefits erroneously provided, if the associate or dependent engaged in any fraud, abuse or deception with respect to the Plan, including but not limited to: Giving false or misleading information to the Plan, Administrator, or on any application or other form; or Making a false statement in connection with enrollment or a claim for benefits.
Leaves of Absence
The Family and Medical Leave Act of 1993 (FMLA) entitles eligible associates to take up to 12 weeks of unpaid, job-protected leave in a 12-month period for specified family and medical reasons. Amendments to the FMLA by the National Defense Authorization Act for FY 2008 (NDAA 2008), expanded the FMLA to allow eligible associates to take up to 12 weeks of jobprotected leave in the applicable 12-month period for any qualifying exigency arising out of the fact that a family member of the associate is deployed, or has been notified of an impending call or order to deployment, to a foreign country as a member of the Armed Forces. NDAA 2008 also amended the FMLA to allow eligible associates to take up to 26 weeks of job-protected leave in a single 12-month period to care for a covered service member with a serious injury or illness. These two types of FMLA leave are known as the military caregiver leave and qualified
exigency leave, respectively. The National Defense Authorization Act for FY 2010 (NDAA 2010) expanded the scope of these military family leave entitlements. The 12-month period is measured backward from the date you use any FMLA leave. If you qualify for an approved family or medical leave of absence, your benefit enrollment will continue for the duration of the leave unless a written request to terminate coverage is received within 30 days of the start of the leave. However, you are responsible to pay any required contributions toward the cost of the coverage. Benefits will be placed into arrears and upon your return the missed deductions will be collected via Rite Aids arrears process. Subject to certain exceptions, if you fail to return to work after the leave of absence, Rite Aid has the right to recover from you any contributions toward the cost of coverage made by it on your behalf during the leave, as outlined in the FMLA. All medical leaves of absence apply toward the 12 weeks allowed under FMLA. Unless dictated otherwise by state law or contractual bargaining agreement, medical leaves of absence (except job illness or injury) have a maximum of 180 days (consecutive or cumulative) in any 365 day period. If you do not return to work upon 180 days of leave, your benefits will be terminated. A COBRA continuation information packet will then be sent to your home address.
Military Leave
If you take an unpaid military leave or leave employment to perform services in the Armed Forces or another uniformed service, you may elect continued group health care coverage under the Plan (including coverage for your eligible dependents) on a self-pay basis as generally described in the COBRA continuation provisions of this booklet. Continuation of health care coverage will be available for up to 24 months. During the period that you remain in the military service, you and you eligible dependents are eligible for health care coverage under this Plan even if they are then also covered under another group health program, such as TRICARE. Except for coverage for illness or injuries incurred or aggravated during the performance of leave duties, no waiting period will be imposed if the period or exclusion would have been satisfied had your coverage not terminated due to the military service absence. You must notify the Rite Aid Benefits Service Center when you return to work.
Summary of Benefits
The benefits provided under the Plan are summarized below. This summary is only a general description of the benefits. Detailed schedules of the benefits available to you under the Plan will be provided to you upon request at no cost. These detailed schedules will identify the specific benefits made available under the applicable various benefits programs or options, including the terms and conditions in regard to the right to receive such benefits.
To receive a detailed schedule of benefits for any benefit program or plan made available to you, please access My Benefits Center, available online via rNation.riteaid.com or www.riteaidbenefits.com, or call the Rite Aid Benefits Service Center at 800-343-1390.
In regard to a medical or other health care plan, the schedule of benefits for such plan will also include (if applicable) a description of the following: Any costsharing provisions, including premiums, deductibles, coinsurance, and copayment amounts for which you or your dependent will be responsible; Any caps or other limits on benefits under the plan; The extent to which preventive services are covered under the plan; Whether, and under what circumstances, existing and new drugs are covered under the plan; Whether, and under what circumstances, coverage is provided for medical tests, devices and procedures; Provisions governing the use of network providers, the composition of the provider network, and whether, and under what circumstances, coverage is provided for out-ofnetwork services; Any conditions or limits on the selection of primary care providers or providers of specialty medical care; Any conditions or limits applicable to obtaining emergency medical care; and Any provisions requiring preauthorizations or utilization review as a condition to obtaining a benefit or service under the plan.
In the case of health care plans with provider networks, the listing of providers will be made available. A copy of the provider list can also be requested at any time without charge upon request to the Contract Administrator. The names and contact information for the insurers or other third party claim administrators for the Plans various benefit programs are included in the Appendix to this booklet.
Medical Benefits
The medical plans made available to eligible associates and their dependents provide comprehensive medical coverage to treat an injury or illness where medically necessary. The services and expenses covered under the medical plans include those described below. Preventive Health Services Womens Health Care Services Hospital Services Maternity Medical and Diabetes Supplies Durable Medical Equipment Emergent/Urgent & Ambulance Services
X-ray & Lab Services Mental Health and Substance Abuse Prescription Drugs
Group health plans, and health insurers, generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mothers or newborns attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours, as applicable). In any case, a medical plan and insurers may not, under Federal law, require that a provider obtain authorization from the plan or the insurer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Dental Care Benefits

The dental care plans made available under the Plan are designed to provide coverage for a wide array of dental expenses. These covered dental care expenses include those identified below. Oral examinations and cleanings Bitewing X-rays Fillings and extractions Fluoride treatments Root canal therapy Inlays and crowns
Vision Care Benefits

The expenses covered under the vision care plans made available to eligible associates and their eligible dependents including these summarized below. Eye examinations Prescription lenses and frames Prescription contacts
Group Term Life Insurance Coverage

The group term life insurance coverage provided under the Plan offers financial protection for the family of eligible associates. The amount of your life insurance coverage is generally a multiple of your annual earnings subject to a specific maximum. You may also be eligible to purchase additional life insurance coverage under the Plan at your own expense.
Accidental Death and Dismemberment Insurance Coverage

The accidental death and dismemberment (AD&D) benefit program provides benefits to you if you are seriously injured in an accident and lose a hand, foot or sight of an eye. Your beneficiary will receive AD&D benefits if you die in an accident.
Long Term Disability Insurance Coverage

If you are in an eligible class, and have enrolled, the Long Term Disability (LTD) benefit program provides you with income protection if you become disabled as a result of a physical disease, mental disorder or accidental bodily injury. LTD benefits are payable after the end of a specified benefit waiting period. This LTD insurance covers only you, not your dependents. After the benefit waiting period, the LTD benefit program provides for a total monthly benefit, equal to a percentage of your basic monthly pay, up to a maximum amount.
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If you become disabled, the amount of your LTD benefit payable under the Plan will be reduced by certain types of income, including the following income: Any income paid as salary, wages or other payment by Rite Aid or any other employer; Any sick pay or other salary continuation paid to you by Rite Aid; Any amount you receive or are eligible to receive under workers compensation law or other similar legislation; and Amounts received from any state disability plan.
Employee Assistance Program and Work-Life Consultation and Referral Service

Through your Employee Assistance Program (EAP), you and your immediate family members can reach a caring, informed, listener someone ready to talk with you about work, family, personal, legal or financial problems 24 hours a day, seven days a week. Your EAP can help you and your loved ones cope with issues. Rite Aid provides this service to you free of charge. EAP professionals can also find the right community resources to assist you. The financial responsibility for additional services outside the EAP is yours. Your medical plan may cover part of these costs. The decision to take advantage of this service is yours. All conversations remain between you and your EAP professional. If an EAP professional becomes concerned about safety and believes a threat of serious harm exists, the law may require that the situation be reported.
Business Travel Accident Insurance Coverage

The Plans business travel accident insurance benefit program provides a benefit to an associate who dies or suffers a serious injury in an accident while traveling on Rite Aid business away from the associates worksite. Rite Aid pays the full cost of this coverage.
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CONTINUATION OF COVERAGE (COBRA)

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you would otherwise lose your group health coverage. It can also be available to other members of your family when they would otherwise lose their group health coverage under the Plan. This section of the booklet is intended to summarize your rights and obligations under COBRA.
COBRA Continuation Coverage

COBRA continuation coverage is continuation of group health coverage provided under the Plan when that coverage would otherwise end because of a life event known as a qualifying event. Specific qualifying events are listed later in this section. Upon the occurrence of a qualifying event, COBRA continuation coverage must be offered to each person who is a qualified beneficiary. You, your spouse, and your dependent children could become qualified beneficiaries if group health coverage under the Plan is lost because of a qualifying event. Samesex domestic partners are not eligible for COBRA coverage except as discussed below. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. The cost for the COBRA continuation coverage is 102% of the Plans cost of the coverage. If you are an associate, you will become a qualified beneficiary if you will lose your group health coverage under the Plan because either one of the following qualifying events happens: Your hours of employment are reduced; or Your employment ends for any reason other than your gross misconduct.
For this purpose, gross misconduct means conduct that reflects an intentional, wanton, willful, deliberate, reckless, or deliberate indifference to Rite Aids interests, or of the associates duties and obligations to Rite Aid. Examples of gross misconduct include, but are not limited to, willful and injurious violations or disregard of Rite Aid policy, including the deliberate disclosure of confidential information; theft; embezzlement; fraud or misappropriation of Rite Aid funds; the willful or attempted damage to Rite Aid property; violence upon persons within the workplace, or non-work related violence affecting the workplace; and deliberate misrepresentations of credentials, education, prior work experience or similar qualifications. Actions arising from mere inefficiency, failure to perform at an expected standard due to inability, inadvertencies, ordinary negligence in isolated instances, or good faith errors in judgment or discretion, will not constitute acts of gross misconduct for COBRA continuation coverage purposes. If you are the spouse of an associate, you will become a qualified beneficiary if you will lose your group health coverage under the Plan because of any of the following qualifying events happens: Your spouse dies; Your spouses hours of employment are reduced; Your spouses employment ends for any reason other than his or her gross misconduct; or You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they will lose group health coverage under the Plan because any of the following qualifying events happens:
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The parent-associate dies; The parent-associates hours of employment are reduced; The parent-associates employment ends for any reason other than his or her gross misconduct; The parents become divorced or legally separated; or The child stops being eligible for coverage under the Plan as a dependent child.
An associates same-sex domestic partner, even if covered under a group health plan, will have no independent COBRA election rights. Though a same-sex domestic partner does not have an independent COBRA election right, if an associate and his or her same-sex domestic partner are both covered by a group health plan, and they together lose coverage upon the associates termination of employment or reduction in hours, the associate may elect COBRA coverage, which would include the same-sex domestic partner and the same-sex domestic partners children, if any.
When COBRA Coverage is Available

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the COBRA Administrator for the Plan has been notified that a qualifying event has occurred. When the qualifying event is the end of an associates employment or a reduction of hours of employment, or the death of the associate, Rite Aid will notify the COBRA Administrator. You Must Give Notice of Certain Qualifying Events For the other qualifying events (divorce or legal separation of the associate and spouse or the dependent childs losing eligibility for coverage as a dependent child), you must notify Rite Aid within 60 days after the end of the month in which the qualifying event occurs. You may notify Rite Aid online, via My Benefits Center (rNation.riteaid.com or www.riteaidbenefits.com), or by calling the Rite Aid Benefits Service Center by calling 1-800-343-1390.
How COBRA Coverage is Provided

Once the COBRA Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. A COBRA election form will be mailed to the individual at the address on record. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. An associate may elect COBRA continuation coverage on behalf of a spouse, and a parent may elect COBRA continuation coverage on behalf of eligible children. COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the associate, your divorce or legal separation, or a dependent childs losing eligibility as a dependent child, COBRA continuation coverage lasts for up to a total of 36 months. When the qualifying event is the end of employment or the reduction of the associates hours of employment, and the associate previously enrolled in Medicare (Part A or Part B), but did so less than 18 months before the qualifying event, then COBRA continuation coverage for qualified beneficiaries other than the associate can last for a period of 36 months after the effective date of the associates enrollment in Medicare. For example, if a covered associate becomes enrolled in Medicare eight months before terminating employment, COBRA continuation coverage for the associates spouse and children can last up to 36 months after the Medicare enrollment date, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or the reduction of the associates hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18
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months. However, there are two ways in which this 18-month period of COBRA continuation coverage can be extended. Disability Extension of 18-Month Period of Continuation Coverage If you or anyone in your family who is receiving group health coverage under the Plan is determined by the Social Security Administration to be disabled and you notify the COBRA Administrator in a timely fashion, as outlined later in this paragraph, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. For the additional 11 months of continuation coverage, you will be charged 150% of the Plans cost of the group health coverage. The disability would have to have th started at some time before the 60 day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. You must make sure that the COBRA Administrator is notified of the Social Security Administrations determination within 60 days of the date of the determination (or, if later, within 60 days after the end of the month in which the qualifying event occurred) and before the end of the 18-month period of COBRA continuation coverage. This notice must be sent to: SHPS Continuation Services P.O. Box 34240 Louisville, KY 40232 (888)556-1939 Second Qualifying Event Extension of 18-Month Period of Continuation Coverage If your family experiences another qualifying event before receiving 18 months of COBRA continuation coverage, the spouse and dependent children in your family can receive up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the COBRA Administrator. This extension may be available to the spouse and dependent children receiving continuation coverage if the associate or former associate dies, or gets divorced or legally separated, or if the dependent child stops being eligible for group health coverage under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose that coverage had the first qualifying event not occurred. In all of these cases, you must make sure that the COBRA Administrator is notified of the second qualifying event within 60 days of the second qualifying event. This notice must be sent to: SHPS Continuation Services P.O. Box 34240 Louisville, KY 40232 (888)556-1939
Other Special Rules

Fully insured HMOs covering associates in California provide that if you are: 60 years of age or older and were employed with Rite Aid for at least five years before the date your employment terminated, or You are the spouse of an associate who dies, divorces, legally separates, or becomes entitled to Medicare, or You are a former spouse of an associate,
then you may continue your coverage until the earliest of: The date you become entitled to Medicare;
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Your 65 birthday; or Five years from the date your COBRA coverage was scheduled to end, if you are an associates spouse or former spouse.
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For information regarding these special rules, including whether they apply to the medical plan in which you are covered, please contact: SHPS Continuation Services P.O. Box 34240 Louisville, KY 40232 (888)556-1939
Flexible Spending Accounts

If you are an associate participating in the Plans health care flexible spending account program and you terminate employment, your COBRA continuation period for the program extends only to the end of the plan year in which your employment terminated.
If You Have Questions

Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to Rite Aid at the address listed below. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District office of the U.S. Department of Labors Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA offices are available through EBSAs website.) Rite Aid Corporation P.O. Box 3165 Harrisburg, PA 17105-3165 (800) 343-1390
Keep Your Plan Informed of Address Changes

In order to protect your familys rights, you should keep Rite Aid informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to Rite Aid.
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Flexible Spending Accounts

The Flexible Spending Account (FSA) program allows you to obtain and pay for certain benefits on a tax-favored basis. The FSA program includes two Spending Accounts. Health Care Spending Account Dependent Care Spending Account
Each plan year, you may elect to participate in one or both types of Spending Accounts. You will need to decide before the beginning of each plan year, how much, if any, you want to contribute to each Spending Account. The plan year is July 1 through June 30. Warning: Use it or lose it. If you have set aside dollars through payroll reduction in the Spending Accounts, and you do not use that money by the end of the plan year, it will be forfeited as prescribed by law.
Enrollment
You must enroll during the open enrollment period before the beginning of each plan year. If you become eligible after the beginning of the plan year, you must enroll within 30 days of your eligibility date or wait until the next regular open enrollment period. You will be given an opportunity to make new elections before the start of each plan year during the open enrollment period. Elections made during the open enrollment period will become effective at the beginning of the next plan year.
Making Election Changes

In general, the law does not permit you to change your Spending Account elections during the plan year. An exception to this general rule will allow you to modify or revoke an election for a year, or elect to enroll in the Spending Accounts for the remainder of the plan year, if you, or your spouse or dependent, incurs such a qualifying life event discussed earlier. However, the modification, revocation or enrollment election must be consistent with and on account of the qualifying life event. Under the IRS rules, a change in election in regard to the Health Care Spending Account because of a qualifying life event will be permitted only if the event affects the coverage of you, your spouse or your dependent under a group health plan. If a judgment, decree, or order resulting from a divorce, legal separation, annulment or change in legal custody (including a Qualified Medical Child Support Order) requires health coverage, a participant may: Change an election to provide coverage for the dependent child (provided that the order requires the participant to provide coverage); or Change an election to revoke coverage for the dependent child if the order requires that another individual (including the participants spouse or former spouse) provide coverage under that individuals plan and such coverage is actually provided.
With respect to the Dependent Care Spending Account, you can modify or revoke your election during a plan year, or elect to enroll in the Spending Account for the remainder of a plan year, under one of the following circumstances:
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You incur a qualifying life event which causes you to incur, or cease to incur, qualified dependent care expenses, such as a child attaining age 13 and thus ceasing to be a qualifying individual; A change in the cost of the dependent care expenses due to a change in the dependent care provider or in the amount of care provided, such as a decrease in the hours of care upon the childs commencement of school; or An increase in the amount charged by the dependent care provider (but only if the provider is not a member of the associates family or household).
If your status changes due to one of these situations, you may make a change in your Spending Account elections. Any new election will be effective on the date determined by Rite Aid, but not earlier than the first pay period beginning after the election is completed. If you cease to be a participant in the FSA program during the year, you may not re-elect coverage for the remaining portion of the plan year unless you have a qualifying life event. Rite Aid reserves the right to limit your elections under the FSA program, if necessary to meet nondiscrimination requirements prescribed by law.
Leave of Absence
If you take a leave of absence due to disability, family or medical leave, or any other reason approved by Rite Aid, you may: Revoke or change your FSA Program election based on a qualifying life event. However, your election change may not reduce the Health Care Spending Account benefit below the amount of benefit used as of the date of the election change. Catch-up, on a pre-tax basis, contributions at the same rate and at the same time (i.e., every payroll period) as before your leave. In that event, the total amount reimbursable for the plan year shall be prorated to take into account the period for which no contributions were paid.
If you do not revoke your election for your period of leave, your contributions will be placed into arrears. Upon your return from leave, your original election will be reinstated for the rest of the plan year unless you have had a qualifying life event and you make a different election. Your contribution amount will be reamortized based upon your original election, the amount you have contributed plan year to date and the remaining pay periods in the plan year. As long as you continue to make contributions to the Spending Account while on leave, you will remain eligible for reimbursement throughout your leave period. However, if you cease to make contributions while you are on leave, you will not be entitled to receive reimbursement for claims incurred during the period when the coverage was terminated. If you elect to reinstate coverage upon return to work, your coverage will be equal to the original election amount for the 12-month period of coverage, prorated for the period when coverage was terminated during leave and reduced by earlier reimbursements.
Additional Information
Additional information regarding the FSA program is available via My Benefits Center accessible online via rNation.riteaid.com or www.riteaidbenefits.com, or you may call the Rite Aid Benefits Service Center at 1-800-343-1390 to request the information.
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The information includes: The types of expenses that are eligible for reimbursement under the FSA program; The maximum amount that you may elect to contribute to each Spending Account for a plan year; and How to receive reimbursement from the Spending Accounts.
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Claim Procedures: Medical Plans

Entitlement to benefits under each of the benefit programs is to be determined by the provisions of all documents forming part of the benefit program. In general, a claim for benefits under a particular benefit program must be made in accordance with the procedures described in the Summary Plan Description (SPD), pertaining to that benefit program. In the event that a claim or dispute concerning benefits under the benefit program should arise under circumstances whereby such claim or dispute is subject to resolution, for example, by the insurance company providing the specific benefit, then the claim or dispute will be processed by the insurance company in accordance with such procedure. If any person believes that he or she is then entitled to receive a benefit under a benefit program, including one greater than that initially determined by the applicable insurance company or other authorized entity, then such person may file a claim for benefits. A response to the claim will be promptly made, and within the time frames prescribed by applicable law.
Claims Procedure for UnitedHealthcare

Network Benefits
In general, if you receive Covered Health Services from a Network provider, UnitedHealthcare will pay the Physician or facility directly. If a Network provider bills you for any Covered Health Service other than your Coinsurance, please contact the provider or call UnitedHealthcare at the phone number on your ID card for assistance. Keep in mind, you are responsible for meeting the Annual Deductible and paying any Coinsurance owed to a Network provider at the time of service, or when you receive a bill from the provider.
Non-Network Benefits
If you receive a bill for Covered Health Services from a non-Network provider, you (or the provider if they prefer) must send the bill to UnitedHealthcare for processing. To make sure the claim is processed promptly and accurately, a completed claim form must be attached and mailed to UnitedHealthcare at the address on the back of your ID card.
If Your Provider Does Not File Your Claim

You can obtain a claim form by visiting www.myuhc.com, calling the toll-free number on your ID card. If you do not have a claim form, simply attach a brief letter of explanation to the bill, and verify that the bill contains the information listed below. If any of these items are missing from the bill, you can include them in your letter: your name and address; the patient's name, age and relationship to the Employee; the number as shown on your ID card; the name, address and tax identification number of the provider of the service(s); a diagnosis from the Physician; the date of service; an itemized bill from the provider that includes: o the Current Procedural Terminology (CPT) codes; o a description of, and the charge for, each service; o the date the Sickness or Injury began; and o a statement indicating either that you are, or you are not, enrolled for coverage under any other health insurance plan or program. If you are enrolled for other coverage you must include the name and address of the other carrier(s).
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Failure to provide all the information listed above may delay any reimbursement that may be due you. After UnitedHealthcare has processed your claim, you will receive payment for Benefits that the Plan allows. It is your responsibility to pay the non-Network provider the charges you incurred, including any difference between what you were billed and what the Plan paid. UnitedHealthcare will pay Benefits to you unless: the provider notifies UnitedHealthcare that you have provided signed authorization to assign Benefits directly to that provider; or you make a written request for the non-Network provider to be paid directly at the time you submit your claim. UnitedHealthcare will only pay Benefits to you or, with written authorization by you, your provider, and not to a third party, even if your provider has assigned Benefits to that third party.
Health Statements
Each month, in which UnitedHealthcare processes at least one claim for you or a covered Dependent, you will receive a Health Statement in the mail. Health Statements make it easy for you to manage your family's medical costs by providing claims information in easy-to-understand terms. If you would rather track claims for yourself and your covered Dependents online, you may do so at www.myuhc.com. You may also elect to discontinue receipt of paper Health Statements by making the appropriate selection on this site.
Explanation of Benefits (EOB)

You may request that UnitedHealthcare send you a paper copy of an Explanation of Benefits (EOB) after processing the claim. The EOB will let you know if there is any portion of the claim you need to pay. If any claims are denied in whole or in part, the EOB will include the reason for the denial or partial payment. If you would like paper copies of the EOBs, you may call the tollfree number on your ID card to request them. You can also view and print all of your EOBs online at www.myuhc.com.
Claim Denials
If your claim for a benefit under any benefit program is denied in whole or in part, you will be notified of such denial in writing. The notice of the denial of the claim will include: The specific reason or reasons for the denial; Specific references to pertinent provisions of the Plan or benefit program of which the denial is based; A description of any additional material or information necessary for you to perfect the claim and an explanation of why such material or information is necessary; An explanation of the applicable claim denial appeal procedure; and The right to bring a civil lawsuit under federal law if the claim denial is upheld under appeal.
If your claim for benefits involves a group health or disability insurance benefit, then the following additional information will be provided: A description of available internal appeals and external review processes, including information regarding how to initiate an appeal;
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The availability of, and contact information for, any applicable office of health insurance consumer assistance or ombudsman established under federal law to assist enrollees with the internal claims and appeals and external review process; Any internal rule, guidelines, protocol or similar criterion relied on in making the claim denial (or state that such information will be provided free of charge upon request); If the claim denial is based on Covered Health Services or experimental treatment, the claim denial notice will include an explanation of the scientific or clinical judgment for the determination, applying plan terms to your medical condition (or state that such information will be provided free of charge upon request).
The criteria for Covered Health Services determinations made with respect to mental health or substance abuse benefits will be made available to any current or potential covered associate or dependent, or any contracting provider upon request.
Claim Appeals
How To Appeal A Denied Claim If you wish to appeal a denied pre-service request for benefits, post-service claim or a rescission of coverage as described below, you or your authorized representative must submit your appeal in writing within 180 days of receiving the adverse benefit determination. You do not need to submit Urgent Care appeals in writing. This communication should include: the patient's name and ID number as shown on the ID card; the provider's name; the date of medical service; the reason you disagree with the denial; and any documentation or other written information to support your request.
You or your authorized representative may send a written request for an appeal to: UnitedHealthcare - Appeals P.O. Box 30432 Salt Lake City, Utah 84130-0432 (877) 440-5978 Expedited Review You may make a request for an expedited review of an adverse benefit determination if: You have filed an appeal of a claim denial, and the claim involves a medical condition for which the otherwise applicable time frame for completion of an appeal would seriously jeopardize the applicable individuals life or health, or would jeopardize the individuals ability to regain maximum function; or A claim is denied upon an appeal, and the applicable individual has a medical condition where the otherwise applicable time frame for completion of a standard external review would seriously jeopardize the life or health of the individual or would jeopardize the individuals ability to regain maximum function, or if the claim concerns an admission, availability of care, continued stay, or health care item or service for which the individual received emergency services, but has not been discharged from a facility.
Notice of the expedited review decision will be provided as expeditiously as the medical condition or circumstances require, but in no event more than 72 hours after the date the claims administrator receives the request for an expedited review.
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For Urgent Care requests for Benefits that have been denied, or for request for an expedited review, you or your provider can call UnitedHealthcare at the toll-free number on your ID card to request an appeal. Types Of Claims The timing of the claims appeal process is based on the type of claim you are appealing. If you wish to appeal a claim, it helps to understand whether it is an: urgent care request for benefits; pre-service request for benefits; post-service claim; or concurrent claim. Review Of An Appeal The claims administrator will conduct a full and fair review of your appeal. The appeal may be reviewed by: an appropriate individual(s) who did not make the initial benefit determination; and a health care professional with appropriate expertise who may not have been consulted during the initial benefit determination process.
You will be provided, free of charge and without a need for request, any new or additional evidence considered, relied upon, or generated by the claims administrator in connection with the claim. The evidence will be provided sufficiently in advance of the date on which the notice of an appeal determination is required to be provided to give you a reasonable opportunity to respond prior to that date. Additionally, if the claims administrator proposes an appeal denial based on a new or additional rationale, you will be provided, free of charge, with the rationale sufficiently in advance of the date on which the notice of the appeal denial is required to be provided to give you a reasonable opportunity to respond prior to that date. Your coverage under a group health benefit program will continue in effect pending the outcome of any appeal. Once the review is complete, if the claims administrator upholds the denial, you will receive a written explanation of the reasons and facts relating to the denial. Filing A Second Appeal Your Plan offers two levels of appeal. If you are not satisfied with the first level appeal decision, you have the right to request a second level appeal from UnitedHealthcare within 60 days from receipt of the first level appeal determination. UnitedHealthcare must notify you of the appeal determination within 15 days after receiving the completed appeal for a pre-service denial and 30 days after receiving the completed post-service appeal. Note: Upon written request and free of charge, any covered persons may examine documents relevant to their claim and/or appeals and submit opinions and comments. UnitedHealthcare will review all claims in accordance with the rules established by the U.S. Department of Labor. External Review Program If, after exhausting your internal appeals, you are not satisfied with the final determination, you may choose to participate in the external review program. This program applies to adverse benefit determinations other than the denial of a claim that is based on a determination that an individual does not satisfy the eligibility requirements of the benefit program.
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This external review program offers an independent review process to review the denial of a requested service or procedure or the denial of payment for a service or procedure. The process is available at no charge to you after exhausting the appeals process identified above and you receive a decision that is unfavorable, or if UnitedHealthcare fails to respond to your appeal within the time lines stated below. You may request an independent review of the adverse benefit determination. Neither you nor UnitedHealthcare will have an opportunity to meet with the reviewer or otherwise participate in the reviewers decision. All requests for an independent review must be made within four (4) months of the date you receive the adverse benefit determination. You, your treating physician or an authorized designated representative may request an independent review by contacting the toll-free number on your ID card or by sending a written request to the address on your ID card. The independent review will be performed by an accredited Independent Review Organization (IRO). The IRO will be engaged by UnitedHealthcare has and will have no material affiliation or interest with UnitedHealthcare or with Rite Aid. UnitedHealthcare will choose the IRO based on a rotating list of approved IROs. In certain cases, the independent review may be performed by a panel of physicians, as deemed appropriate by the IRO. Within applicable timeframes of UnitedHealthcares receipt of a request for independent review, the request will be forwarded to the IRO, together with: all relevant medical records; all other documents relied upon in making a decision on the case; and all other information or evidence that you or your Physician has already submitted to UnitedHealthcare.
If there is any information or evidence you or your physician wish to submit in support of the request that was not previously provided, you may include this information with the request for an independent review, and UnitedHealthcare will include it with the documents forwarded to the IRO. A decision will be made within applicable timeframes. If the reviewer needs additional information to make a decision, this time period may be extended. The independent review process will be expedited if you meet the criteria for an expedited external review as defined by applicable law. The reviewers decision will be in writing and will include the clinical basis for the determination. The IRO will provide you and the vendor with the reviewers decision, a description of the qualifications of the reviewer and any other information deemed appropriate by the organization and/or as required by applicable law. If the final independent decision is to approve payment or referral, the Plan will accept the decision and provide benefits for such service or procedure in accordance with the terms and conditions of the Plan. If the final independent review decision is that payment or referral will not be made, the Plan will not be obligated to provide benefits for the service or procedure. You may contact UnitedHealthcare at the toll-free number on your ID card for more information regarding your external review rights and the independent review process.
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Timing Of Appeals Determinations Separate schedules apply to the timing of claims appeals, depending on the type of claim. There are three types of claims: Urgent Care Request for Benefits - a request for benefits provided in connection with Urgent Care services; Pre-Service Request for Benefits - a request for benefits which the Plan must approve or in which you must notify UnitedHealthcare before non-Urgent Care is provided; and Post-Service - a claim for reimbursement of the cost of non-Urgent Care that has already been provided.
The tables below describe the time frames which you and the claims administrator (UnitedHealthcare) are required to follow. Urgent Care Request for Benefits
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Type of Request for Benefits or Appeal If your request for benefits is incomplete, the claims administrator must notify you within: You must then provide completed request for benefits to the claims administrator within: The claims administrator must notify you of the benefit determination within: If the claims administrator denies your request for benefits, you must appeal an adverse benefit determination no later than: The claims administrator must notify you of the appeal decision within:
Timing 24 hours 48 hours after receiving notice of additional information required 72 hours 180 days after receiving the adverse benefit determination 72 hours after receiving the appeal
*You do not need to submit Urgent Care appeals in writing. You should call UnitedHealthcare as soon as possible to appeal an Urgent Care request for Benefits.
Pre-Service Request for Benefits Type of Request for Benefits or Appeal If your request for benefits is filed improperly, the claims administrator must notify you within: If your request for benefits is incomplete, the claims administrator must notify you within: You must then provide completed request for benefits information to the claims administrator within: Timing 5 days 15 days 45 days
The claims administrator must notify you of the benefit determination: If the initial request for benefits is complete, within: after receiving the completed request for Benefits (if the 15 days 15 days
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Pre-Service Request for Benefits Type of Request for Benefits or Appeal initial request for benefits is incomplete), within: You must appeal an adverse benefit determination no later than: The claims administrator must notify you of the first level appeal decision within: You must appeal the first level appeal (file a second level appeal) within: The claims administrator must notify you of the second level appeal decision within: 180 days after receiving the adverse benefit determination 15 days after receiving the first level appeal 60 days after receiving the first level appeal decision 15 days after receiving the second level appeal* Timing
* UnitedHealthcare may require a one-time extension of no more than 15 days only if more time is needed due to circumstances beyond their control.
Post-Service Claims Type of Claim or Appeal If your claim is incomplete, the claims administrator must notify you within: You must then provide completed claim information to the claims administrator within: Timing 30 days 45 days
The claims administrator must notify you of the benefit determination: if the initial claim is complete, within: after receiving the completed claim (if the initial claim is incomplete), within: 30 days 30 days 180 days after receiving the adverse benefit determination 30 days after receiving the first level appeal 60 days after receiving the first level appeal decision 30 days after receiving the second level appeal*
You must appeal an adverse benefit determination no later than: The claims administrator must notify you of the first level appeal decision within: You must appeal the first level appeal (file a second level appeal) within: The claims administrator must notify you of the second level appeal decision within:
* UnitedHealthcare may be entitled to a one-time extension of no more than 15 days only if more time is needed due to circumstances beyond their control.
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Authorized Representation An authorized representative may act on your behalf with respect to a benefit claim or appeal under these procedures. However, no person will be recognized as an authorized representative until the Plan receives an Appointment of Authorized Representative form signed by the claimant, except that for urgent care claims the Plan will, even in the absence of a signed Appointment of Authorized Representative form, recognize a health care professional with knowledge of the claimants medical condition (e.g. the treating physician) as the claimants authorized representative unless the claimant provides specific written direction otherwise. An assignment for purposes of payment does not constitute appointment of an authorized representative under these claims procedures. Once an authorized representative is appointed, the Plan will direct all information and notification regarding the claim to the authorized representative until the claimant provides specific written direction otherwise. Any reference in these claims procedures to claimant is intended to include the authorized representative of such claimant appointed in compliance with the above procedures. An Appointment of Authorized Representative form may be obtained online through My Benefits Center accessible via rNation.riteaid.com or www.riteaidbenefits.com, or by calling the Rite Aid Benefits Service Center at (800) 343-1390. Concurrent Care Claims If an on-going course of treatment was previously approved for a specific period of time or number of treatments, and your request to extend the treatment is an Urgent Care request for benefits as defined above, your request will be decided within 24 hours. UnitedHealthcare will make a determination on your request for the extended treatment within 24 hours from receipt of your request. If an on-going course of treatment was previously approved for a specific period of time or number of treatments, and you request to extend treatment in a non-urgent circumstance, your request will be considered a new request and decided according to post-service or pre-service timeframes, whichever applies. Limitation of Action You cannot bring any legal action against Rite Aid or the Claims Administrator to recover reimbursement until 90 days after you have properly submitted a request for reimbursement as described in this section and all required reviews of your claim have been completed. If you want to bring a legal action against Rite Aid or the Claims Administrator, you must do so within three years from the expiration of the time period in which a request for reimbursement must be submitted or you lose any rights to bring such an action against Rite Aid or the Claims Administrator. You cannot bring any legal action against Rite Aid or the Claims Administrator for any other reason unless you first complete all the steps in the appeal process described in this section. After completing that process, if you want to bring a legal action against Rite Aid or the Claims Administrator you must do so within three years of the date you are notified of our final decision on your appeal or you lose any rights to bring such an action against Rite Aid or the Claims Administrator.
Claims Procedure for Highmark

Medical Claims
A claim is an itemized statement of charges for health care services and/or supplies provided by a facility, professional or other provider. After you have received the services and/or supplies, a
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claim requesting payment is sent to your local Blue Shield plan. Either you or the provider submits the claim following the procedures outlined below. When Highmark Blue Shield receives a claim from your provider, it will be processed in accordance with your Plan and the payment will be issued directly to the provider. If you should ever receive a claim directly from a provider, and it is for an amount other than the copayment or other amount for which you are responsible, please send the claim to: Highmark Blue Shield P.O. Box 890173 Camp Hill, PA 17089-0173 Claims must be submitted within one year from the date the service was rendered in order to be considered for payment. All claims submitted to the plan must include the following: Patients full name, date of birth, and address; Patients Highmark Blue Shield identification number (as shown on patients identification card); Date each service or supply was provided; A description and/or procedure code for each service; Diagnosis, illness, or injury for each service; Amount charged for each service; Number of units for each service; Name and address of provider (on providers official bill or letterhead); and Location where services were provided, if other than physicians office.
Most of the time the provider will submit a claim on your behalf. However, if you find it necessary to submit your claim, request an itemized bill from the provider. To simplify this process, complete a claim form. You can request a form by contacting the Rite Aid Dedicated Unit: Phone: 1-866-246-9309 The following information must be provided in order for us to process your claim. Provide this information for each itemized bill submitted. 1. Itemized Bill Patients full name Date each service or supply was provided Type(s) of service or supply A description of service rendered or procedure code Diagnosis, illness or injury for each service Amount charged for each service or supply Number of units Name and address of provider (on providers invoice or letterhead) Where services were provided Coordination of Benefits Information
2. Contract Information Subscribers first and last name Identification Number and Group Number (as shown on the identification card) Patients date of birth
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3. Claims for certain services may require you or the provider to submit additional information such as: Medical Records which may include physician notes and/or treatment plans Workers Compensation payment or rejection notice Accident information (i.e., date of the accident, type of accident, payment or rejection notice, letter of benefit exhaustion, itemized statement) Other insurance payment or rejection notices including a Medicare Summary Notice if applicable. Student information Ambulance information point of origin and destination Private Duty Nursing nurses name and professional status (R.N., L.P.N., etc,); the nurses registration or license number
If you need help in submitting a claim, contact Customer Service at 1-866-246-9309. Out of Area Claims Associates who receive medical services while traveling or residing outside of the Highmark Blue Shield service area may benefit from the BlueCard Program. Claims submitted through the BlueCard Program are considered received when the claim reaches the Rite Aid Dedicated Unit. You may need to submit additional information with the out of area claim such as medical records. Rite Aid Dedicated Unit Highmark Blue Shield 1800 Center Street, 1A,L1 Camp Hill, PA 17011
Claim Denials
If your claim for a benefit under any benefit program is denied in whole or in part, you will be notified of such denial in writing. The notice of the denial of the claim will include: The specific reason or reasons for the denial; Specific references to pertinent provisions of the Plan or benefit program on which the denial is based; A description of any additional material or information necessary for you to perfect the claim and an explanation of why such material or information is necessary; An explanation of the applicable claim denial appeal procedures; and The right to bring a civil lawsuit under federal law if the claim denial is upheld under appeal.
If your claim for benefits involves a group health or disability insurance benefit, then the following additional information will be provided: A description of available internal appeals and external review processes, including information regarding how to initiate an appeal; The availability of, and contact information for, any applicable office of health insurance consumer assistance or ombudsman established under federal law to assist enrollees with the internal claims and appeals and external review processes; Upon request and free of charge, any internal rule, guidelines, protocol or similar criterion relied on in making the claim denial (or state that such information will be provided free of charge upon request);
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Upon request and free of charge, If the claim denial is based on medical necessity or experimental treatment, the claim denial notice will include an explanation of the scientific or clinical judgment for the determination, applying plan terms to your medical condition (or state that such information will be provided free of charge upon request).
The criteria for medical necessity determinations made with respect to mental health or substance abuse benefits will be made available to any current or potential covered associate or dependent, or any contracting provider upon request.
Claim Appeals
How To Appeal A Denied Claim If you wish to appeal a denied pre-service request for benefits, post-service claim or a rescission of coverage as described below, you or your authorized representative must submit your appeal in writing within 180 days of receiving the adverse benefit determination. You do not need to submit Urgent Care appeals in writing. This communication should include: the patient's name and ID number as shown on the ID card; the provider's name; the date of medical service; the reason you disagree with the denial; and any documentation or other written information to support your request.
You or your authorized representative may send a written request for an appeal to: Highmark Member Grievance and Appeals Department P.O. Box 535095 Pittsburgh, PA 15253-5095 Attention: Review Committee (866) 246-9309 Expedited External Review You may make a request for an expedited external review of an adverse benefit determination of claim involving medical judgment or a rescission of coverage if: You have filed an appeal of a claim denial, and the claim involves a medical condition for which the otherwise applicable time frame for completion of an appeal would seriously jeopardize the applicable individuals life or health, or would jeopardize the individuals ability to regain maximum function; or A claim is denied upon an appeal, and the applicable individual has a medical condition where the otherwise applicable time frame for completion of a standard external review would seriously jeopardize the life or health of the individual or would jeopardize the individuals ability to regain maximum function, or if the claim concerns an admission, availability of care, continued stay, or health care item or service for which the individual received emergency services, but has not been discharged from a facility.
For purposes of the foregoing, medical judgment includes medical necessity, appropriateness of care, health care setting, level of care, effectiveness of a covered benefit or determinations as to whether a treatment or procedure is experimental or investigational. Notice of the expedited review decision will be provided as expeditiously as the medical condition or circumstances require, but in no event more than 72 hours after the date the claims administrator receives the request for an expedited review.
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For Urgent Care requests for Benefits that have been denied, or for request for an expedited review, you or your provider can call Highmark at the toll-free number on your ID card to request an appeal. Types Of Claims The timing of the claims appeal process is based on the type of claim you are appealing. If you wish to appeal a claim, it helps to understand whether it is an: urgent care request for benefits; pre-service request for benefits; post-service claim; or concurrent claim. Review Of An Appeal The claims administrator will conduct a full and fair review of your appeal. The appeal may be reviewed by: an appropriate individual(s) who did not make the initial benefit determination; and a health care professional with appropriate expertise who was not consulted during the initial benefit determination process.
You will be provided, free of charge and without a need for request, any new or additional evidence considered, relied upon, or generated by the claims administrator in connection with the claim. The evidence will be provided sufficiently in advance of the date on which the notice of an appeal determination is required to be provided to give you a reasonable opportunity to respond prior to that date. Additionally, if the claims administrator proposes an appeal denial based on a new or additional rationale, you will be provided, free of charge, with the rationale sufficiently in advance of the date on which the notice of the appeal denial is required to be provided to give you a reasonable opportunity to respond prior to that date. Your coverage under a group health benefit program will continue in effect pending the outcome of any appeal. Once the review is complete, if the claims administrator upholds the denial, you will receive a written explanation of the reasons and facts relating to the denial. Filing A Second Appeal Your Plan offers two levels of appeal. If you are not satisfied with the first level appeal decision, you have the right to request a second level appeal from Highmark within 45 days from receipt of the first level appeal determination. Highmark will notify you of the appeal determination within 30 days after receiving the completed appeal for a pre-service denial and 30 days after receiving the completed post-service appeal. Your decision to proceed with a second level review of a pre-service denial by Highmark is voluntary. In other words, you are not required to pursue the second level review of a pre-service denial by Highmark before pursuing a claim for benefits in court under 502 of ERISA. Should you elect to pursue the second level review before filing a claim for benefits in court, the Plan: Will not later assert in a court action that you failed to exhaust administrative remedies (i.e. you failed to proceed with a second level review) prior to the filing of the lawsuit; Agrees that any statute of limitations applicable to the claim for benefits [will not commence (i.e. run) during the second level review; and
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Will not impose any additional fee or cost in connection with the second level review.
Note: Upon written request and free of charge, any covered persons may examine documents relevant to their claim and/or appeals and submit opinions and comments. Highmark will review all claims in accordance with the rules established by the U.S. Department of Labor. External Review Program If, after exhausting your internal appeals, you are not satisfied with the final determination, you may choose to participate in the external review program. This program applies to adverse benefit determinations that involve Medical Judgment This external review program offers an independent review process to review the denial of a requested service or procedure or the denial of payment for a service or procedure. The process is available at no charge to you after exhausting the appeals process identified above and you receive a decision that is unfavorable, or if Highmark fails to respond to your appeal within the time lines stated below. You may request an independent review of the final adverse benefit determination involving medical judgment (as defined above) or a rescission of coverage. Neither you nor Highmark will have an opportunity to meet with the reviewer or otherwise participate in the reviewers decision. All requests for an independent review must be made within four (4) months of the date you receive the final adverse benefit determination. Note that for Highmark pre-service denials, the four (4) month period begins to run from the date you received Highmarks first-level adverse benefit determination. You, your treating physician or an authorized designated representative may request an independent review by contacting the toll-free number on your ID card or by sending a written request to the address on your ID card. The independent review will be performed by an accredited Independent Review Organization (IRO). The IRO will be engaged by Highmark and will have no material affiliation or interest with Highmark or with Rite Aid. Highmark will choose the IRO based on a rotating list of approved IROs. In certain cases, the independent review may be performed by a panel of physicians, as deemed appropriate by the IRO. Within applicable timeframes of Highmarks receipt of a request for independent review, the request will be forwarded to the IRO, together with: all relevant medical records; all other documents relied upon in making a decision on the case; and all other information or evidence that you or your Physician has already submitted to Highmark.
If there is any information or evidence you or your physician wish to submit in support of the request that was not previously provided, you may include this information with the request for an independent review, and Highmark will include it with the documents forwarded to the IRO. A decision will be made within applicable timeframes. If the reviewer needs additional information to make a decision, this time period may be extended. The independent review process will be expedited if you meet the criteria for an expedited external review as defined by applicable law. The reviewers decision will be in writing and will include the clinical basis for the determination. The IRO will provide you and the vendor with the reviewers decision, a description of the
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qualifications of the reviewer and any other information deemed appropriate by the organization and/or as required by applicable law. If the final independent decision is to approve payment or referral, the Plan will accept the decision and provide benefits for such service or procedure in accordance with the terms and conditions of the Plan. If the final independent review decision is that payment or referral will not be made, the Plan will not be obligated to provide benefits for the service or procedure. You may contact Highmark at the toll-free number on your ID card for more information regarding your external review rights and the independent review process. Timing Of Appeals Determinations Separate schedules apply to the timing of claims appeals, depending on the type of claim. There are three types of claims: Urgent Care Request for Benefits - a request for benefits provided in connection with Urgent Care services; Pre-Service Request for Benefits - a request for benefits which the Plan must approve or in which you must notify Highmark before non-Urgent Care is provided; and Post-Service - a claim for reimbursement of the cost of non-Urgent Care that has already been provided.
The tables below describe the time frames which you and the claims administrator (Highmark) are required to follow. Urgent Care Request for Benefits
*
Type of Request for Benefits or Appeal If your request for benefits is incomplete, the claims administrator must notify you within: You must then provide completed request for benefits to the claims administrator within: The claims administrator must notify you of the benefit determination within: If the claims administrator denies your request for benefits, you must appeal an adverse benefit determination no later than: The claims administrator must notify you of the appeal decision within:
Timing 24 hours 48 hours after receiving notice of additional information required 72 hours 180 days after receiving the adverse benefit determination 72 hours after receiving the appeal
*You do not need to submit Urgent Care appeals in writing. You should call Highmark as soon as possible to appeal an Urgent Care request for Benefits.
Pre-Service Request for Benefits
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Type of Request for Benefits or Appeal You must appeal an adverse benefit determination no later than:
Timing 180 days after receiving the adverse benefit determination 30 days after receiving the first level appeal decision 45 days after receiving the first level appeal decision 30 days after receiving the second level appeal
The claims administrator must notify you of the first level appeal decision within: You must appeal the first level appeal (file a second level appeal) within: The claims administrator must notify you of the second level appeal decision within: Post-Service Claims Type of Claim or Appeal If your claim is incomplete, the claims administrator must notify you within: The claims administrator must notify you of the benefit determination once a completed claims is received: You must appeal an adverse benefit determination no later than: The claims administrator must notify you of the first level appeal decision within: You must appeal the first level appeal (file a second level appeal) within: The claims administrator must notify you of the second level appeal decision within:
Timing 30 days 30 days 180 days after receiving the adverse benefit determination 30 days after receiving the first level appeal 45 days after receiving the first level appeal decision 30 days after receiving the second level appeal
Authorized Representation An authorized representative may act on your behalf with respect to a benefit claim or appeal under these procedures. However, no person will be recognized as an authorized representative until the Plan receives an Appointment of Authorized Representative form signed by the claimant, except that for urgent care claims the Plan will, even in the absence of a signed Appointment of Authorized Representative form, recognize a health care professional with knowledge of the claimants medical condition (e.g. the treating physician) as the claimants authorized representative unless the claimant provides specific written direction otherwise. An assignment for purposes of payment does not constitute appointment of an authorized representative under these claims procedures. Once an authorized representative is appointed, the Plan will direct all information and notification regarding the claim to the authorized representative until the claimant provides specific written direction otherwise. Any reference in these claims procedures to claimant is intended to include the authorized representative of such claimant appointed in compliance with the above procedures.
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An Appointment of Authorized Representative form may be obtained online through My Benefits Center accessible via rNation.riteaid.com or www.riteaidbenefits.com, or by calling the Rite Aid Benefits Service Center at (800) 343-1390. Concurrent Care Claims If an on-going course of treatment was previously approved for a specific period of time or number of treatments, and your request to extend the treatment is an Urgent Care request for benefits as defined above, your request will be decided within 24 hours. Highmark will make a determination on your request for the extended treatment within 24 hours from receipt of your request. If an on-going course of treatment was previously approved for a specific period of time or number of treatments, and you request to extend treatment in a non-urgent circumstance, your request will be considered a new request and decided according to post-service or pre-service timeframes, whichever applies. Limitation of Action You cannot bring any legal action against Rite Aid or the Claims Administrator to recover reimbursement until 90 days after you have properly submitted a request for reimbursement as described in this section and all required reviews of your claim have been completed. If you want to bring a legal action against Rite Aid or the Claims Administrator, you must do so within three years from the expiration of the time period in which a request for reimbursement must be submitted or you lose any rights to bring such an action against Rite Aid or the Claims Administrator. You cannot bring any legal action against Rite Aid or the Claims Administrator for any other reason unless you first complete all the steps in the appeal process described in this section. After completing that process, if you want to bring a legal action against Rite Aid or the Claims Administrator you must do so within three years of the date you are notified of our final decision on your appeal or you lose any rights to bring such an action against Rite Aid or the Claims Administrator.
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Claim Procedures: Dental Plan

Dental plan claim forms may be obtained online at Delta Dentals website, www.deltadentalins.com/riteaid, or you may call Delta Dentals Customer Service Center at (800) 471-4810
Complaints, Grievances and Appeals

Our commitment is to ensure quality throughout the entire treatment process: from the courtesy extended to participants by Delta Dentals customer service representatives to the dental services provided by Participating Dentists. If you have questions about any services received, we recommend that you first discuss the matter with your dentist. However, if you continue to have concerns, please call Delta Dentals Customer Service Center at (800) 471-4810. Delta Dental attempts to process all claims within 30 days. If a claim will be delayed more than 30 days, Delta Dental will notify the enrollee in writing within 30 days stating the reason for delay. Questions or complaints regarding eligibility, the denial of dental services or claims, the policies, procedures, or operations of Delta Dental, or the quality of dental services performed by the dentist may be directed in writing to Delta Dental or by calling Delta Dental toll-free at (800) 4714810. You can also e-mail questions by accessing the Contact Us section of Delta Dentals web site at www.deltadentalins.com/riteaid. A grievance is a written expression of dissatisfaction with the provision of services or claims practices of Delta Dental. When you write, please include the name of the enrollee, the primary enrollees name and enrollee ID, and your telephone number on all correspondence. You should also include a copy of the claim form, Benefits Statement, Invoice or other relevant information.
Appeals
Any dissatisfaction with adjustments made or denials of payment should be brought to Delta Dentals attention, and if unresolved to your satisfaction, to the Plan Administrator. The Plan Administrator will advise you of your rights of appeal or other recourse. Appeals on claims denied must be submitted in writing. The following section explains the claim review and appeal process and time limits applicable to such process. This information can also be found in your Benefits Statement. If a post-service claim is denied in whole or in part, Delta Dental will notify you and your attending dentist of the denial in writing within 30 days after the claim is filed, unless special circumstances require an extension of time, not exceeding 14 days, for processing. If there is an extension, you and your attending dentist will be notified of the extension and the reason for the extension within the original 30-day period. If an extension is necessary because either you or your attending dentist did not submit the information necessary to decide the claim, the notice of extension will specifically describe the required information. You or your attending dentist will be afforded at least 45 days from receipt of the notice within which to provide the specific information. The extension period (15 days) within which a decision must be made by Delta Dental will begin to run from the date on which the response is received by the plan (without regard to whether all of the requested information is provided) or, if earlier, the due date established by the plan for furnishing the requested information (at least 45 days). The notice of denial shall explain the specific reason or reasons why the claim was denied in whole or in part, including a specific reference to the pertinent contract provisions on which the denial is based, a description of any additional material or information necessary for you to perfect the claim and an explanation as to why such information is necessary. The notice of
35
denial shall also contain an explanation of Delta Dentals claim review and appeal process and the time limits applicable to such process, including a statement of the enrollees right to bring a civil action under ERISA upon completion of Delta Dentals second level of review. The notice shall refer to any internal rule, guideline, and protocol that was relied upon (and that a copy will be provided free of charge upon request). The notice shall state that if the claim denial is based on lack of dental necessity, experimental treatment or a clinical judgment in applying the terms of the contract, an explanation is available free of charge upon request by you or your attending dentist. If you or your attending dentist wants the denial of benefits reviewed, you or your attending dentist must write to Delta Dental within 180 days of the date on the denial letter. In the letter, you or your attending dentist should state why the claim should not have been denied. Also any other documents, data, information or comments which are thought to have bearing on the claim including the denial notice should accompany the request for review. You or your attending dentist are entitled to receive upon request and free of charge reasonable access to and copies of all documents, records, and other information relevant to the denied claim. The review will take into account all comments, documents, records, or other information, regardless of whether such information was submitted or considered in the initial benefit determination. The review shall be conducted on behalf of Delta Dental by a person who is neither the individual who made the claim denial that is the subject of the review, nor the subordinate of such individual. If the review is of a claim denial based in whole or in part on a lack of dental necessity, experimental treatment, or a clinical judgment in applying the terms of the contract, Delta Dental shall consult with a dentist who has appropriate training and experience in the pertinent field of dentistry and who is neither the Delta Dental dental consultant who made the claim denial nor the subordinate of such consultant. The identity of the Delta Dental dental consultant whose advice was obtained in connection with the denial of the claim whether or not the advice was relied upon in making the benefit determination is also available to you or your attending dentist on request. In making the review, Delta Dental will not afford deference to the initial adverse benefit determination. If after review, Delta Dental continues to deny the claim, Delta Dental will notify you and your attending dentist in writing of the decision on the request for review within 30 days of the date the request is received. Delta Dental will send to you or your attending dentist a notice, which contains the specific reason or reasons for the adverse determination and reference to the specific contract provisions on which the benefit determination is based. The notice shall state that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of all documents, records and other information relevant to your claim for benefits. The notice shall refer to any internal rule, guideline, and protocol that was relied upon (and that a copy will be provided free of charge upon request). The notice shall state that if the claim denial is based on lack of dental necessity, experimental treatment or a clinical judgment in applying the terms of the contract, an explanation is available free of charge upon request by either you or your attending dentist. The notice shall also state that you have a right to bring an action under ERISA upon completion of Delta Dentals second level of review, and shall state: You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency. If in the opinion of you or your attending dentist, the matter warrants further consideration, you or your attending dentist should advise Delta Dental in writing as soon as possible. The matter shall then be immediately referred to Delta Dentals Dental Affairs Committee. This stage can include a clinical examination, if not done previously, and a hearing before Delta Dentals Dental Affairs Committee if requested by you or your attending dentist. The Dental Affairs Committee will render a decision within 30 days of the request for further consideration. The decision of the Dental Affairs Committee shall be final insofar as Delta Dental is concerned. Recourse thereafter would
36
be to the state regulatory agency, a designated state administrative review board, or to the courts with an ERISA or other civil action. Send your grievance, appeal, or claims review request to Delta Dental at the address shown below:
Delta Dental One Delta Drive Mechanicsburg, PA 17055
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Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information The Rite Aid Corporation Master Welfare Benefit Plan (the Plan) will create, receive and maintain records that contain health information about you as necessary to administer the Plan and provide you with health care benefits. This notice describes the Plans health information privacy policy and practices. The notice informs you of the ways the Plan may use and disclose health information about you, and describes your rights and the obligations of the Plan regarding the use and disclosure of your health information. Pledge Regarding Health Information Privacy The privacy practices of the Plan are designed to safeguard confidential health information (including genetic information) that identifies you, and which relates to a physical or mental health condition or the payment of your health care expenses. This identifiable health information will not be used or disclosed without a written authorization from you, except as described in this notice or as otherwise permitted by applicable 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; provide you with this notice of the Plans legal duties and privacy practices with respect to health information about you; and abide by the terms of this notice.
How the Plan May Use and Disclose Health Information About You The different ways that the Plan may use and disclose your health information are described below. For Payment. The Plan will use and disclose your health information to properly pay for claims for health care treatment, services and supplies that you receive from health care providers. For example, the Plan may receive and maintain information regarding a persons surgical procedure so as to enable the Plan to process the hospitals claim for payment of the surgical procedure. For Health Care Operations. The Plan may use and disclose your health information to enable it to perform its operations or to facilitate the provision of benefits to persons covered under the Plan. For example, the Plan may use your health information to develop ways to reduce health care costs or to arrange for medical review. For Treatment. The Plan may use and disclose your health information to a health care provider who renders treatment on your behalf. For example, a pharmacist may be provided with your prescription history in order to detect potential drug interactions. To the Company. The Plan may disclose your health information to designated Company personnel so they can carry out their Plan-related administrative functions, including the uses and disclosures described in this notice. These individuals will protect the privacy of your health information and ensure that it is used only as described in this notice or as permitted by law.
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To a Business Associate. The Plan may disclose health information to other persons or organizations, known as business associates, who provide services on the Plans behalf. For example, the Plan may hire an administrative firm to process claims made under the Plan. To protect your health information, the Plan requires its business associates to appropriately safeguard the health information disclosed to them. Treatment Alternative. The Plan may use and disclose your health information to inform you of possible treatment options or alternatives that may be of interest to you. Health-Related Benefits and Services. The Plan may use and disclose your health information to inform you of health-related benefits or services that may be of interest to you. Individual Involved in Your Care or Payment of Your Care. The Plan may disclose health information to a close friend or family member involved in or who helps pay for your health care. As Required by Law. The Plan will disclose your health information when required to do so by federal, state or local law.
Special Use and Disclosure Situations The Plan may also use or disclose your health information under the circumstances described below. Judicial and Administrative Proceedings. The Plan may disclose your health information in response to a court or administrative order, a subpoena, warrant, discovery request or other lawful process. Law Enforcement. The Plan may release your health information if asked to do so by a law enforcement official. For example, the Plan may disclose health information to a police officer if needed to help find or identify a missing person. Workers Compensation. The Plan may disclose your health information as necessary to comply with applicable workers compensation or similar laws. To Avert Serious Threat to Health or Safety. The Plan may use and disclose your health information when necessary to prevent a serious threat to your health and safety, or to the health and safety of the public or another person. Public Health Activities. The Plan may disclose health information about you for public health activities, such as providing information to an authorized public health authority for the purpose of preventing or controlling a disease, injury or disability. Health Oversight Activities. The Plan may disclose your health information to a health oversight agency for audits, investigations, inspections and licensure necessary for the government to monitor the health care system and government programs, or to ascertain compliance with applicable civil rights laws. Specified Government Functions. In certain circumstances, federal regulations require the Plan to use or disclose your health information to facilitate specified government functions related to the military and veterans, national security and intelligence activities, protective services for the President and others, and correctional institutions and inmates.
39
Coroners and Medical Examiners. The Plan may release your health information to a coroner or medical examiner. This may be necessary, for example, to identify the cause of a persons death.
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 health information, you may revoke the authorization, in writing, at any time. If you revoke your authorization, the Plan will no longer disclose or use your health information for the reasons covered by your written authorization. However, the Plan will not retract any uses or disclosures previously made as a result of your prior authorization. Protection of Genetic Information Genetic information about you or your family members may not be used or disclosed by the Plan for activities relating to the creation, renewal, or replacement of a contract of health insurance or health benefits, or for any other underwriting purpose. Notification of Significant Breach of Privacy of Health Information You will be promptly notified if the Plan or a business associate discovers a significant breach of the privacy of your health information. The Department of Health and Human Services will also be notified of the breach. A breach is considered to be significant if it exposes you to a substantial risk of financial, reputational or other harm. Your Rights Regarding Your Health Information You have the rights regarding your health information that are described below. Right to Inspect and Copy. You have the right to inspect and copy your health information maintained by the Plan. Your request must be in writing and should be submitted to the Privacy Official. The Plan may charge a fee for the costs of copying and mailing your request. In limited circumstances, the Plan may deny your request to inspect and copy your health information. Generally, if you are denied access to health information, you may request a review of the denial. Right to Amend. If you feel that your health information maintained by the Plan is incorrect or incomplete, you may ask the Plan to amend it. You have the right to request an amendment for as long as the information is maintained by the Plan. To request an amendment, you must send a detailed request in writing to the Privacy Officer. You must provide the reasons supporting your request. The Plan may deny your request if the health information requested to be amended is in fact accurate and complete, not created by the Plan, not part of the health information maintained by the Plan, or not information that you are otherwise permitted to inspect and copy. Right to an Accounting of Disclosures. You have the right to request a list of your health information that has been disclosed by the Plan, other than disclosures made (i) for treatment, payment or health plan operations; (ii) to you, or to a person involved in your care; (iii) to a law enforcement custodial official, or for national security purposes; or (iv) in a manner which removed information that identified you. The request must be made in writing to the Privacy Officer. The request must specify the time period for which you are requesting the information (for example, disclosures made during the six months preceding the date of the request). The Plan is not required to provide an accounting for disclosures made more than six years prior to the request.
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Right to Request Restrictions. You may request restrictions on the Plans use and disclosure of your health information for treatment, payment or health care operation purposes. You also have the right to request a restriction on the Plans disclosure of your health information to someone involved in the payment of your care. For example, you may request that the Plan not disclose to a family member information regarding particular surgery that you have had. A request for restrictions must be made in writing to the Privacy Officer. However, the Plan is not required to agree to your request unless (i) the disclosure is to be made by the Plan to another health plan for purposes of carrying out payment or health care operations (rather than for treatment purposes); (ii) the health information pertains solely to a health care item or service for which the health care provider involved has been paid out-of-pocket in full; and (iii) the Plan is not otherwise obligated by law to disclose the health information. Right to Receive Confidential Communications. You have the right to request that the Plan communicate with you in a certain way if you feel the disclosure of your health information could endanger you. For example, you may ask that the Plan only communicate with you at a certain telephone number or by email. If you wish to receive confidential communications, please make your request in writing to the Privacy Officer. Your request must specify how or where you wish to be contacted. The request must also include a statement that the disclosure of all or part of the information to which the request pertains could endanger you. The Plan will attempt to honor your reasonable requests for confidential communications. Right to Receive Certain Information in Electronic Format. If the Plan uses or maintains your health information in an electronic format, then upon your request, the Plan will provide you with a copy of your health information in such format. In addition, upon your request, the Plan will transmit the copy directly to an entity or person you designate, provided that the directive is clear and specific. A request for an electronic copy of your health information should be submitted to the Privacy Officer. Right to a Paper Copy of This Notice. You have a right to request and receive a paper copy of this notice at any time, even if you have previously received this notice. To obtain a paper copy, please contact the Privacy Officer. You also may obtain a copy of the current version of the notice at the Plans web site which is accessible through My Benefits Center at rNation.riteaid.com, or by logging on to www.riteaidbenefits.com. Changes to this Notice The Plan reserves the right to change the terms of this notice at any time in the future. If the notice is revised, the provisions of the new notice will apply to all health information thereafter maintained by the Plan. Until such time as a notice is revised, the Plan is required by law to comply with the current version of the notice. Complaints Concerns or complaints about the Plans safeguarding of your health information should be directed to the Privacy Officer. The Plan will not retaliate against you in any way for filing a complaint. All complaints must be submitted in writing. If you believe your privacy rights have been violated, you may also file a complaint with the Office of Civil Rights, U.S. Department of Health and Human Services.
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Privacy Officer If you have any questions regarding the matters covered by this notice, please contact the Plans designated Privacy Officer, as follows: Privacy Officer, Rite Aid Corporation, PO Box 3165, Harrisburg, PA 17105, (717) 761-2633.
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Statement of ERISA Rights

As a participant in this Plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). Information About Your Plan and Benefits ERISA provides that all Plan participants are entitled to: Examine, without charge, at Rite Aid Corporations corporate office and at other specified locations such as worksites, all documents governing the Plan, including insurance contracts, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor, and available at the Public Disclosure Room of the Employee Benefits Security Administration. Obtain, upon written request to the Group Vice President, Compensation, Benefits, and Shared Services of Rite Aid Corporation, 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 the updated summary plan description. Rite Aid may make a reasonable charge for the copies. Receive a summary of the Plans annual Form 5500. Rite Aid is required by law to furnish each participant with a copy of this summary annual report.
Continue Group Health Plan Coverage You also have the right to continue health care coverage for yourself, your spouse or your 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 summary plan description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights.
Prudent Actions by Plan Fiduciaries

In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit 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 or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA.
Enforcing Your Rights

If your claim for a 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 (Form 5500) 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 Rite Aid Corporation, as 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.
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If you have a claim for benefits that is denied or ignored, in whole or in part, you may request a review of the claim denial. That request must be made in accordance with the Plans claim procedures. If the claim is denied at the appeal level, you may then file suit in a Federal court. In addition, if you disagree with the Plans decision or lack thereof concerning the qualified status of a medical child support order and you have exhausted the plans internal administrative procedures pertaining to such procedures, you may file suit in a Federal court. If it should happen that Plan fiduciaries misuse the Plans 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 federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees -- for example, if it finds your claim is frivolous.
Assistance With Your Questions

If you have any questions about your plan, you should contact Rite Aid Corporation. If you have any questions about this statement or about your rights under ERISA, or you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor (listed in your telephone directory) or contact the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, NW, Washington, D.C. 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.
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Information About The Plan

General information regarding the sponsorships and administration of the Plan is set forth below. 1. 2. The Plan's official name is: Rite Aid Corporation Master Welfare Benefit Plan The Plan Sponsor and Plan Administrator is: Rite Aid Corporation P.O. Box 3165 Harrisburg, PA 17105-3165 (717) 761-2633 3. 4. 5. The Plan Number assigned by the Plan Sponsor is: 501 The IRS Employer Identification Number (EIN) of the Sponsor is: 23-1614034 The Plans agent for legal process is: Group Vice President, Compensation, Benefits and Shared Services Rite Aid Corporation P.O. Box 3165 Harrisburg, PA 17105-3165 The records of the health plan are kept on the basis of a policy year which begins on July 1st and ends on the following June 30th. The plan year for government reporting purposes is March 1 through the last day of February. 6. The Plan is an employee benefits plan providing medical, dental, vision, prescription drug, employee assistance, long term disability, group term life insurance, accidental death and dismemberment insurance, and dependent care assistance benefits.
Amendment or Termination of Plan

Rite Aid intends to continue to maintain the Plan indefinitely. However, it reserves the right at any time and from time to time to amend or terminate in whole or in part any of the provisions of the Plan or any of the benefit programs forming part of the Plan. Any such amendment or termination may take effect retroactively or otherwise. In the event of a termination or reduction of benefits under the Plan or any benefit program, the Plan will be liable only for benefit payments due and owing as of the effective date of such termination or reduction, and no payments scheduled to be made on or after such effective date will result in any liability to the Plan or Rite Aid.
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Appendix
Contract Administrators
The companies listed below provide claims processing and other administrative services to the Plan on a contract (third party) administration basis. However, they do not underwrite or otherwise guarantee the payment of the benefits under the Plan. All medical plan benefits will be offered through Highmark Blue Cross Blue Shield or UnitedHealthcare. You carrier will be determined based on the state where you live, as follows: Highmark covers associated who live in Indiana, Michigan, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Virginia and West Virginia UnitedHealthcare covers associates in all other states. Harvard Pilgrim Health Care is the Plans Claims Administrator for Covered Persons who reside within the state of Massachusetts, Maine and New Hampshire.
The third party administrator for the medical plans in Indiana, Michigan, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Virginia and West Virginia identified on your enrollment worksheet and confirmation statement is: Highmark Blue Shield PO Box 890173 Camp Hill, PA 17089 0173 (866) 246-9309 The third party administrator for the medical plans in all other states and identified on your enrollment worksheet and confirmation statement is: UnitedHealthcare P.O. Box 740800 Atlanta, GA 30374-0800 (877) 440-5978 The third party administrator for the medical plans in Massachusetts, Maine and New Hampshire is Harvard Pilgrim Health Care: You may contact the Claims Administrator by phone at the number on your ID card or in writing at: United HealthCare Services, Inc. 185 Asylum St. Hartford, CT 06103-3408
HPHC Insurance Company 93 Worcester Street Wellesley, MA 02481-9181
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The third party administrator for the prescription drug benefit program is: Rite Aid Health Solutions 30 Hunter Lane Camp Hill, PA 17011 (800) 277-1657 The third party administrator for the dental PPO benefit program is: Delta Dental One Delta Drive Mechanicsburg, PA 17055 (800) 471-4810
The third party administrator for the flexible spending account benefit program is: UnitedHealthcare P.O. Box 740800 Atlanta, GA 30374-0800 (877) 440-5978
The third party administrator for Work/Life Consultation and Referral Service benefit program (including EAP services) is: RIEAS 300 Centerville Road Suite 301 South Warwick, RI 02886 (800) 833-0453
Insurance Companies
The contact information for insurance companies that underwrite the benefits under particular benefit programs is set forth below. The insurance companies are responsible for the payment and the administration of the claims made under the benefit program. The insurance company for the vision program is: Vision Service Plan Insurance Company 3333 Quality Drive Rancho Cordova, CA 95670 The insurance company for the life insurance, basic accidental death and dismemberment program and long term disability is: The Prudential Insurance Company of America 751 Broad St. Newark, NJ 07102 The insurance company for the additional accident program is: Hartford Life Group Insurance Company 2 North LaSalle Street, Suite 2500 Chicago, IL 60602
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The insurance company for the group legal program is: Hyatt Legal Plans, Inc. 1111 Superior Avenue Cleveland, OH 44114-2507 The insurance company for the business travel accident coverage is: National Union Fire Insurance Company of Pittsburgh, PA 70 Pine Street New York, NY 10270 This Appendix identifies the contract administrators and insurance companies for the Plan as of July 1, 2011.
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SPD Ra Spd2011

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Rite Aid Corporation

Master Welfare Benefit Plan

Effective July 1, 2011

7/1/11 Rite Aid Corporation MWP

Qualified Medical Child Support Orders

7/1/11 Rite Aid Corporation MWP

7/1/11 Rite Aid Corporation MWP

When Coverage Begins

Special Enrollment Period

7/1/11 Rite Aid Corporation MWP

Qualifying Life Events

7/1/11 Rite Aid Corporation MWP

7/1/11 Rite Aid Corporation MWP

7/1/11 Rite Aid Corporation MWP

7/1/11 Rite Aid Corporation MWP

7/1/11 Rite Aid Corporation MWP

Dental Care Benefits

Vision Care Benefits

Group Term Life Insurance Coverage

Accidental Death and Dismemberment Insurance Coverage

Long Term Disability Insurance Coverage

7/1/11 Rite Aid Corporation MWP

Employee Assistance Program and Work-Life Consultation and Referral Service

Business Travel Accident Insurance Coverage

7/1/11 Rite Aid Corporation MWP

CONTINUATION OF COVERAGE (COBRA)

COBRA Continuation Coverage

7/1/11 Rite Aid Corporation MWP

When COBRA Coverage is Available

How COBRA Coverage is Provided

7/1/11 Rite Aid Corporation MWP

Other Special Rules

7/1/11 Rite Aid Corporation MWP

Flexible Spending Accounts

If You Have Questions

Keep Your Plan Informed of Address Changes

7/1/11 Rite Aid Corporation MWP

Flexible Spending Accounts

Making Election Changes

7/1/11 Rite Aid Corporation MWP

7/1/11 Rite Aid Corporation MWP

7/1/11 Rite Aid Corporation MWP

Claim Procedures: Medical Plans

Claims Procedure for UnitedHealthcare

If Your Provider Does Not File Your Claim

7/1/11 Rite Aid Corporation MWP

Explanation of Benefits (EOB)

7/1/11 Rite Aid Corporation MWP

7/1/11 Rite Aid Corporation MWP

7/1/11 Rite Aid Corporation MWP

7/1/11 Rite Aid Corporation MWP

7/1/11 Rite Aid Corporation MWP

7/1/11 Rite Aid Corporation MWP

Claims Procedure for Highmark

7/1/11 Rite Aid Corporation MWP

7/1/11 Rite Aid Corporation MWP

7/1/11 Rite Aid Corporation MWP

7/1/11 Rite Aid Corporation MWP

7/1/11 Rite Aid Corporation MWP

7/1/11 Rite Aid Corporation MWP

Pre-Service Request for Benefits

7/1/11 Rite Aid Corporation MWP