2005-048 Health Insurance for Village Employees-United Healthcare~'
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RESOLUTION 48-2005
A RESOLUTION OF THE VILLAGE COUNCIL OF THE VILLAGE OF NORTH PALM
BEACH-, FLORIDA, ACCEPTING THE PROPOSAL OF UNITED HEALTHCARE, TO
PROVIDE THE VILLAGE WITH HEALTH INSURANCE FOR VILLAGE EMPLOYEES,
WHICH PROPOSAL IS ATTACHED TO THIS RESOLUTION AS EXHIBIT "A" AND
MADE PART HEREOF; AUTHORIZING THE MAYOR AND VILLAGE CLERK TO
EXECUTE SUCH DOCUMENTS AND AGREEMENTS NECESSARY TO IMPLEMENT
THIS ACCEPTANCE; AND, PROVIDING FOR AN EFFECTIVE DATE.
BE IT RESOLVED BY THE VILLAGE COUNCIL OF NORTH PALM BEACH, FLORIDA:
Section 1. The Village Council of the Village of North Palm Beach, Florida, does hereby
accept the proposal of United Healthcare to provide the Village with health insurance for Village
employees, which proposal is attached to this resolution as Exhibit "A" and made part hereof.
Section 2. The Mayor and Village Clerk are hereby authorized to execute such documents
and agreements necessary to implement acceptance of the United Healthcare proposal.
Section 3. This resolution shall take effect immediately upon its adoption.
PASSED AND ADOPTED THIS 26th DAY OF ME` v ~nnc
'1)11111, 11
111 111
(Vill'age Seal) '~., ,
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VILLAGE CLERK
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Disclosure Statements
Statement of Confidentiality
By accepting and reviewing the contents of this Response to the Request for Proposal
("Response"), the Employer group, the Employer group's agents or other designees agree to the
extent permitted by law that certain information contained herein, or other information provided
in connection with this request for proposal, is proprietary and/or confidential to
UnitedHealthcare, and its related entities, and may not be copied, used, distributed or disclosed
without prior written consent from an authorized representative of UnitedHealthcare, other than
is necessary to evaluate this Response. We consider much of the information contained in the
Response to be proprietary or otherwise confidential, and are releasing this Response on the
understanding that the Employer group, the Employer group's agents or other representatives
will only use it and any data included in the Response for the specific purpose of evaluating its
content. If this is not consistent with your understanding, please notify us before reviewing the
Response.
In addition, this Response is subject to negotiation and execution of a written agreement, which
will supersede the contents of this Response. This Response does not constitute an agreement,
and is based on assumptions made from the written information in our possession and provided
by you. We retain the right to modify our Response if the information upon which this Response
is based is changed or is supplemented.
Statement of Quality Assurance
The goal of UnitedHealthcare's Quality Assurance Plan is to continuously improve the care and
services provided by our health care delivery system. Through our plan, we establish high
standards for all our quality improvement activities, including:
^ Promoting and incorporating quality into our operational structure and processes.
^ Monitoring and evaluating patient care and services to ensure that requirements of good
medical practice are being met.
^ Identifying and analyzing improvement opportunities with action plans and follow-up.
^ Coordinating quality improvement, risk management and patient safety activities.
^ Maintaining compliance with local, state, and federal regulatory requirements and
accreditation standards.
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QH-CL-B-MNRP-Confidentiality
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FINANCIAL EXHIBIT
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UNITED HEALTHCARE FINANCIAL EXHIBITS -MEDICAL
Village of North Palm Beach
Effective Date: July 1, 2005
Option #1 Option #2
PLAN OFFERED
Overture Package Name N/A NIA
Plan Name NRH (10 C INS) WLG (61 C+ INS)
Overture Plan NIA NIA
Product Choice ' Choice Plus '
Locations National -Excl. OOA National -Excl. OOA
Plan Offering Dual Option Dual Option
Multiple Option with: Option(s) 2 Option(s) 1
i-Plan HRA or HSA No No
RATES
Employee $331.08 $315.69
Emplo ee + Famil $1,019.33 $971.94
ASSUMED ENROLLMENT
Employee 34 47
Emplo ee + Famil 30 63
Monthly Premium $41,836 $76,069
Annual Premium $502,038 $912,834
BENEFITS'
In-Network:
Office Copay (PCP/SPC) $20 Per Visit $20 Per Visit
Other Copays (IP/ER/UC) $2501$100/$50 N/A/$100/$50
Deductible (Individual/Family) ' "' NIA $250/500
Coinsurance 100% 80%
Out-of-Pocket (Individual/Family) NIA $2,000/4,000
Pharmacy $7/25140 $7125/40
Out of Network:
Deductible N/A $50011,000
Coinsurance NIA 60%
Out of Pocket NIA $4,00018,000
'High level benefit summary. Please see your plan summary for more detailed benefit description.
Page I of Z 5%14/1005 9 04 AM
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UNITED HEALTHCARE FINANCIAL EXHIBITS -MEDICAL
Village of North Palm Beach
Effective Date: July 1, 2005
Medical Quote Assumptions
The rates quoted here are based on the following assumptions. Changes to these assumptions may result in an adjustment to rates or revocation of the quote.
- Rates are guaranteed for 12 months for the contract period of 711105 through 6/30/06.
- UnitedHealthcare is the only carrier offered.
-UnitedHealthcare reserves the right to adjust the rates if the enrollment at issue varies by +/_ 10% from the submitted census.
-Employer contributes a minimum of 100% toward the employee only rates and 0% toward the dependent rates.
- Requires a minimum participation level of 90%.
-COBRA continuees make up 10% or less of covered employees.
- Quote is subject to final underwriting which may have conditions. Additional paperwork and/or information may be required.
- Preliminary rates are subject to an employer form approval process which may include a telephone interview.
- Quote assumes no out of area or retiree lives.
-Unless otherwise stated, this offer replaces and renders all previous offers null and void.
-Includes Deductible rollover from previous carrier, if applicable.
Agents may receive commissions and other compensation for selling the products in this proposal, and this cost may be directly or indirectly reflected in the premium or fees.
Agent compensation is subject to disclosure on Form 5500 for customers governed by ERISA. It is our policy to exclude from bonus payments any case in which the agent
is receiving a consulting fee from a customer. Contact your~agent if you have questions on their compensation for the products in this proposal. ~ `
Page 2 oj2 5/24/2005 9: 04 :9M
UNITED HEALTHCARE FINANCIAL EXHtRi'rc _ naenr~
..._~ .. ........... . a„„ ~~a~tt
Effective Date: July 1, 2005
Plan Options
Plan One In Network'
OV IP FR r it
Out Of Network•
Emolovee Pnrin~
NRH 10 C INS $20
$250
$100 vv
$50 ~"~
N/A 1°v~
100 % VVP DED COINS OOP Em to ee + Famil Variance
NRK
34CINS
510
$250
$100
$50
N/A
90% N!A
$1
000/2
000 NIA N/A N/q
$358.67
$1,104.27
0.0%
BGA FL C01 Choice $10 N/A $100 $35
N/A
90 % ,
,
$1000/2000 N/A N/A N/A $354.81 $1,092.40 -1.1
NRE 7 C INS
$15
N!A
$100
$35
$250/500
100%
N/A N/A N/A N/A $353.71 $1,089.02 -1.4
BGI
FL C09 Choice
$10
$500
$100
$35
N/A
90 %
$2000/4000 N/A N/A N/A
$352.70
$1,065.91
-1.7%
BGJ FL C10 Choice $15 $500 $100 $35
N/A
90%
$20 N/A N/q N/A $351.17 $1,081.19 -2.1
OAH
FL 556 C Ins
$15125
$500
$150
$50
N/A
100% 00/4000
$2500/5000 NIA N/A N/A $347.96 $1,071.32 -3.0%
OAE FL S53 C Ins $20 $1,000 $100 $50 N/A 100% $2500/5000 N/A NIA NIA $347.33 $1,069.38 -3.2%
OAJ FL 558 C Ins $20/30 $250/day x 5 $150 $50 N/A 100 % $2500/5000 N/A N/A N/A $344.49 $1,060.61 -4.0
BGB FL C02 Choice $15 N/A $100 $35
$100/200
90%
$2000/4000 N/A N/A N/A $342.67 $1,055.01 -4.5%
BGC
FL C03 Choice
$15
N/A
$100
$35
$200/400
90 %
$200 N/A N/A N/A $342.49 $1,054.45 -4.5%
NRF
BCINS
$15
N/A
$100
$50
$250/500
90% 0/4000
$2
000/4
000
N/A
NIA
N/A
$338.25
$1,041.41
-5.7%
BGD FL C04 Choice $15 N/A $100
$35
$250/500
90% ,
,
$2000/4000 NIA N/A N/A $336.47 $1,035.92 -6.2
OAF
FL 554 C Ins
$25
$500/day x 3
$100
$50
N/A
100 %
$2500/5000 N/A N/A N/A $336.38 $1,035.64 -6.2%
BGE FL C05 Choice $20 N/A $100
$35
$250/500
90%
$2000/4000 N/A N/A N/A $335.80 $1,033.87 -6.4
NRL
36 C INS
$10
N/A
$100
$50
$500/1,000
90%
$1
500/3
000 N/A N/A
N/A
$333.15
$1,025.71
-7.1%
OAI FL S57 C Ins $25140 $500/day x 3 $150 575
NIA
100% ,
,
$2500/5000 N/A NIA NIA $332.45 $1,023.55 -7.3
NRG 9CINS
515
N/A
$100
$50
$500/1,000
90%
$2
500/5
000 N/A N/A N/A $330.23 $1,016.73 -7.9%
NRI
11 C INS
$20
N/A
$100
$50
$500/1,000
90% ,
,
$3
000/6
000 N/A N/A N/q
$327.19
$1,007.35
-8.8%
OAG FL 555 C Ins
$25/50
$500/da x 5
$150
$50
N/A
0o
100 / ,
,
$250015000 N/A N/A
N/A
$323.33
$995.48
-9.9%
N/A N/A N/A $323.15 $994.92 -9.9
Plan Options
Plan Two In Network•
DV IP FA 1Ir
Out Of Network'
WLG 61 C+ INS
$20
NIA
$100 `"~"
$50 ""'
$250!500 `'""'" VUP DED COINS OOP
NLK
EWB
11C+INS
$20
N/A
$100
$50
$500/1,000 80%
90% $2,000/4,000
$3
000/6
000 $500/1,000
$1
00012
000 60%
7 $4,000/8,000
$341.99
$1,052.93
0.0%
BGP 75C+INS
FLCO6Choice+
$/5
$20
N/A
$100
$50
$750/1,500
90% ,
,
$2,500/5,000 ,
,
$1,500/3
000 0%
70% $6,000112,000
$5
000/10
000 $340.76 $1,049.13 -0.4%
WLI
63 C+ INS
$20 N/A
NIA $100
$100 535
$50 $50011000 80% $2000/4000 ,
$750/1500
60% ,
,
$5000/10000 $336.78
$333.00 $1,036.89
$1
025
24 -1.5%
2
6
EWC
76 C* INS
$25
NIA
$100
$50
$500/1.000
$750/1
500
80 %
90
$2.000/4,000
$1,000/2,000
60%
$4,000/8,000
$332.98 ,
.
$1,025.18 -
.
%
6/0
2
WLB 51 C+ INS $20 N/A $50 $35 ,
N/A %
70% $2,000/4,000 $1,500/3,000 70°/ $6,000/12,000 $331.23 $1,019.79 .
-3
1
FEC FL S50 C+ INS (51 $20
N/A
$50
$35
N/A $5,000/10,000 $1,000/2,000 60% $8,500/17,000 $330.12 $1
016
37 .
-3
5%
EWD
77C+INS
$20
N/A
$100
$50
$1
000/2
000 70%
90% $5000/10000 ESOD/1000 60% $8500/17000 $330.09 ,
.
$1,016.28 .
-3
5%
NLL 12C+INS $20 N/A $100
$50 ,
,
$500/1,000
80% $2,000/4,000
$4
000/8
000 $2.000/4,000 70% $8,000/16,000 $326.89 $1,006.44 .
-4.4%
EWE
78C+INS
$20
N/A
$100
$50
$750/1
500
80% ,
, $1,000/2,000 60% $8,000/16,000 $325.49 $1,002.11 -4
8%
BGO
FL C07 Choice+
$25
N/A
$100
$35 ,
$500/1000
BO % $2,000!4,000
$5000/10000
$1,500/3,000
60%
$4,000/8,000
$325.30
$1,001.52 .
-4.9%
EWF 79C+INS $25 N/A $100
$50
$750/1,500
80%
$4
000/8
000 $1000/2000
$1 60% $5000/10000 $321.76 $990.63 _$.go/
NLM
13 C+ INS
$25
N/A
$100
$50
$1,000/2,000
80% ,
,
$2
000/4
000 ,500!3,000 60% $8,000/16,000 $315.22 $970.49 -7.8%
NLP
16 C+ INS
$20
$250
$150
$50
$1,500/3,000
80% ,
,
$5
000/10
000 $2.000/4,000
$3
00 60% $8,000/16,000
$314.97
$969.73
-7.9%
,
, ,
0!6,000 60% $10,000/20,000 $310.63 $956.38 _g.2%
,'Benefits for Plan One indude pharmacy plan: $7/25140; 2.5x for M.O.; Plan Two indudes pharmacy plan: $7125140; 2.Sx for M.O.
- Any plan from the Plan One options can be combined with any plan from the Plan Two options as long as the pricing variance between the two plans is at least 5
and no more than 15 % .
Quote Assumptions: The rates quoted are based on the lollowing assumptions. Changes to these assumptions may result in an adjustment to the rates orrevocation ollhe quote.
-Rates are guaranteed for 12 months for the contrail period of 7/1105 through 6/30106.
- UnitedHealthcare is the only carrier offered.
- United Healthcare reserves the right to adjust the rates if the enrollment at issue varies by +/- 10 % from the census of 174 subscribers.
-Employer contributes a minimum of 100 % toward the employee only rates and 0% toward the dependent rates.
- Requires a minimum participation level of 90%.
-COBRA continuees makeup 10 % or less of covered employees.
- Ouote is subjed to final underwriting which may have conditions. Additional paperwork and/or information may be required.
- Preliminary rates are subjed to an employer form approval process which may indude a telephone interview.
- Ouote assumes no out of area or retiree lives.
- Unless otherwise stated, this offer replaces and renders all previous offers null and void.
- Includes Deductible rollover from previous tamer, i/applicable.
'High level benefit summary. Please see your plan summary for more detailed bene(It description.
53/2005 18.36
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UNITEDHEALTHCARE NETWORK FACTS
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~TNITED~EAIJTHCARE 1~1ETV4tORK FACTS
• PRACTICAL, INNOVATIVE SOLUTIONS FOR HEALTH CARE COVERAGE
At UnitedHealthcare, we apply practical innovation to offer affordable products and services with unmatched network access
to quality care. Our unique clinical solutions provide consumers and physicians with the resources and support necessary to
improve health care outcomes, satisfaction and affordability. Our investment in new technology offers consumers, employers,
brokers and physicians streamlined, online administrative capabilities. Innovative product designs span the spectrum from
traditional indemnity products to consumer-defined plans that give employers more opportunities to design affordable benefit
programs that best meet their employees' needs.
A NATIONAL LEADER
-- We provide health benefits coverage to over 20 million health care consumers across the United States.
We offer network access to over 4,000 hospitals and 470,000 physicians nationally. Please visit
unitedhealthcare.comfnr our online directory, or to learn more about our products and capabilities.
Our consumer-focused Web site, myuhc.com®, offers personal benefit and claim information, as well as access to
our online directory, and a wide selection of health and well-being topics.
Our innovative Care Coordinations"' program inspires patients to take better care of themselves, while also providing
clinical support to their physicians. Over the past year, we facilitated care for nearly 710,000 enrolled individuals
and identified 348,000 gaps in care. We had consultative interactions with physicians regarding the care of 56,990
patients; 23% of these discussions resulted in changed treatment plans. Nine out of ten consumers surveyed said
Care Coordination created a better health care experience for them.
-- Currently, over 139,000 customers and brokers use our Benefits Administration Web site, Employer eServicess'"
This site has helped them perform, on average, over 976,000 real-time eligibility transactions a month.
COMMITTED TO THE LOCAL MARKETS WE SERVE
Miami, Florida Network -Choice and Choice Plus products:
Dan Rosenthal, CEO
1362/ N. W /2th Street, Sunrise FL 33323-2806
_ Approximately 504,208 individuals have chosen to enroll with UnitedHealthcare in our South Florida market
_ In Miami, Florida we are contracted with over 1,983 Primary Physicians, 3,515 Specialists and 52 Hospitals for our Choice
and Choice Plus products
Our board certification rates are as follows: Primary Physicians 72.01%; Specialty Physicians 71.29%
UnitedHealthcare has been in operation in Florida since March 1973
_ UnitedHealthcare is accredited by JCAHO for all our commercial and Medicare products in Florida
Our contracts reimburse on the following bases: Inpatient Hospital - 4% discount off charges, 96% per diem; Primary
Physicians - 2% discount off charges, 98% fee schedule; Specialty Physicians- IS% discount off charges, 85% fee
schedule
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Page - 1 Verification date: 12/31/2004
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SUMMARY OF BENEFITS
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YOUR BENEFITS
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~J~itedHealthcare
Choice Plan 010
Choice plan gives you the freedom to see any Physician or other health
care professional from our Network, including specialists, without a
referral. With this plan, you will receive the highest level of benefits
when you seek care from a network physician, facility or other health
care professional. In addition, you do not have to worry about any
claim forms or bills. ;
Some of the Important Benefits
You have access to a Network of
physicians, facilities and other health care
professionals, including specialists, without
designating a Primary Physician or
obtaining a referral.
of Your Plan:
Emergencies are covered anywhere in the
world.
Pap smears are covered.
Prenatal care is covered.
Benefits are available for office visits and
hospital care, as well as inpatient and
outpatient surgery.
Care Coordinationst"I services are available
to help identify and prevent delays in care
for those who might need specialized help.
Routine check-ups are covered.
Childhood immunizations are covered.
Mammograms are covered.
Vision and hearing screenings are covered.
FLNEM01002
Choice Benefits Summary
Types of Coverage Network Benefits /Copayment Amounts
• This Benefit Summary is intended only to highlight Annual Deductible: No Annual Deductible.
your Benefits and should not be relied upon to fully
determine coverage. This benefit plan may not cover Out-of-Pocket Maximum: No Out-of-Pocket Maximum.
all of your health care expenses. More complete
descriptions of Benefits and the terms under which Maximum Policy Benefit: No Maximum Policy Benefit.
they are provided are contained in the Certificate of
Coverage that you will receive upon enrolling in the
Plan.
If [his Benefit Summary conflicts in any way with the
Policy issued to your employer, the Policy shall
prevail.
Terms that are capitalized in the Benefit Summary are
defined in the Certificate of Coverage.
Benefits are payable (or Covered Health Services
provided by or under the direction of your Network
physician.
*Prior Notification is required for certain services.
1. Ambulance Services -Emergency only Ground Transportation: No Copayment
Air Transportation: 0% of Eligible Expenses
2. Dental Services -Accident only *No Copayment
*Prior notification is required before follow-up treatment begins.
3. Durable Medical Equipment No Copayment
Benefits for Durable Medical Equipment are
limited to $2,500 per calendar year Limits do not
apply to Durable Medical Equipment classified as
diabetic equipment or supplies.
4. Emergency Flealth Services $100 per visit
5. Eye Examinations $20 per visit
Refractive eye examinations are limited to one
every other calendar year from a Network
Provider
6. Home Aealth Care No Copayment
Benefits are limited to 60 visits for skilled care
services per calendar year.
7. Hospice Care No Copayment
Benefits are limited to 360 days during the entire
period of time a Covered Person is covered under
the Policy.
8. Hospital -Inpatient Stay $250 per Inpatient Stay
9. Injections Received in a Physician's Office $20 per visit
10. Maternity Services Same as 8, i 1, 12 and 13
No Copayment applies to Physician ofTice visits for prenatal care after the first visit.
1I.Outpatient Surgery, Diagnostic and Therapeutic
Services
Outpatient Surgery . No Copayment
Outpatient Diagnostic Services For lab and radiology/Xray: No Copayment
Outpatient Diagnostic/Therapeutic Services - CT No Copayment
Scans, Pet Scans, MRI and Nuclear Medicine
Outpatient Therapeutic Treatments No Copayment
12. Physician's Office Services
Covered Health Services for preventive medical $20 per visit. No Copayment applies when a Physician charge is not assessed.
care.
Covered Health Services for the diagnosis and $20 per visit. No Copayment applies when a Physician charge is not assessed.
treatment of a Sickness or Injury.
13. Professional Fees for Surgical and Medical No Copayment
Services
14. Prosthetic Devices No Copayment
Benefits for prosthetic devices are limited to
$2,500 per calendar year.
15. Reconstructive Procedures Same as 8, I I, 12, 13 and 14
YOUR BENEFITS
Types of Coverage Network Benefits /Copayment Amounts
16. Rehabilitation Services -Outpatient Therapy $20 per visit
Benetts are limited as follows: 20 visits of
• physical therapy: 20 visits ofoccupational theraPY;
20 visits of speech therapy; 20 visits of pulmonary
rehabilitation; and 36 visits of cardiac
rehabilitation per calendar year.
17. Skilled Nursing Facility/Inpatient No Copayment
Rehabilitation Facility Services
Benefits are limited to 60 days per calendar year.
18. Transplantation Services 'No Copayment
19. Urgent Care Center Services $50 per visit
Additional Benefits
Bones or Joints of the Jaw and Facial Region Same as 8, 11, 12 and 13
Child Health Supervision Services Same as I I, 12, 13 and 16
Cleft Lip/Cleft Palate Treatment Same as 8, 11, 12, 13, and 16
Dental Procedures -Anesthesia and Hospitalization Same as 8, 11, and 13
Diabetes Treatment Same as 3, 11, l2 and 13
Mammography No Copayment
Mastectomy Same as 8, 11, 12 and 13
dental Health and Substance Abuse Services - $20 per individual visit; $ IS per group v~stt.
Outpatient
Must receive prior authorization through the Mental
Health/Substance Abuse Designee. Benefits are
limited to 30 visits per calendar year.
dental Health and Substance Abuse Services - $250 per Inpatient Stay
Inpatient and Intermediate
Must receive prior authorization through the Mental
Health/Substance Abuse Designee. Benefits are
limited to 30 days per calendar year.
vsreoporosis treatment Same as 1 ], 12 and 13
Prescription and Non-Prescription Enteral No Copayment
Formulas
Benefits for low protein food products for Covered
Persons through age 24 are limited to $2,500 per
calendar year.
Spinal Treatment $20 per visit
Benefits include diagnosis and related services and are
limited to one visit and treatment per day. Benefits are
limited to 24 visits per calendar year.
•
Exclusions
United Healthcare Insurance Company
Except as may be specifically provided in Section I of the Certificate o(Coverage (COC) or through a
Rider to the Policy, the fuilowing are not eovered:
A. Alternative Treatments
• Acupressure, hypnotism. rolling; massage theraPY: aromatheraPY: acupuncture, and other forms of
alternative treatment.
B. Comfort or Convenience
Personal comfort or convenience items or services such as television; telephone; barber or beauty
service; guest service, supplies, egwpment and similar incidental services and supplies for personal
comfort including air conditioners, air purifiers and filters, batteries and battery chargers,
dehumidif ors and humidifiers; devices or computers to assist rn communication and speech.
C. Dental
Except as specifically described az covered in Section 1 0(the COC under the headings Denra!
Servrces - Acndenr only and C/ej7 Lip/GeP Palate Treatment, dental services are excluded. There is
no coverage for services provided for the prevention, diagnosis, and treatment of the teeth or gums
(including extraction, restoration, and replacement of teeth and services to improve dental clinical
outcomes) Dental implants and dental braces are excluded Dental x-rays, supplies and appliances and
all associated expenses arising out of such dental services (including hospitalizations and anesthesia)
are excluded, except as might otherwise be requred (or transplant preparation, initiation of
immunosuppressives, the direct treatment of acute traumatic Injury, cancer, or cleft palate, or as
described in Section t of the COC under the heading of Denra! Procedarer - Anee7hesia and
Norpiralrzalion Treatment far congenitally missing, malpositioned, or super numerary teeth is
excluded, even if part of a Congenital Anomaly except in connection with cleft lip or cleft palate.
D. Drugs
Prescription drug products Cor outpatient use that are filled by a prescription order or refill Self-
injectable medications except as described in Section 1 of the COC under the heading of Diabetes
Treatment Non-injectable medications given in a Physician's office except as required m an
Emergency Over-the-counter drugs and treatments
E. Experimental, Investigational or Unproven Services
Experimental, Investigational or Unproven Services are excluded, except (a) bone marrow transplants
and (b) medically appropriate medications prescribed for the treatment ofcancer, for a particular
indication, i(that drug is recognized for the treatment of that indication in a standard reference
compendium or recommended in medical literature. The fact that an Experimemal, Investigational or
Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a
partmular condition will not result in Benefits if the procedwe is considered to be Experimental,
Investigational or Unproven in the «eatment of that particular conddion.
E Foot Care
Routine foot care (mdudmg the cutting or removal of corns and calluses), nail trimming, cutting, or
debriding; hygienic and preventive maintenance foot care, treatment of Flat feet or subluxation of the
foot; shoe orthotics.
O Medical Supplies and Appliances
Devices used spea5cally as safety Hems or to affect performance primarily msports-related activities
Prescribed or non-prescribed medical supplies and disposable supplies mdudmg but not limited to
elastic stockings, ace bandages, gauze and dressings, ostomy supplies, syringes and diabetic test steps.
Orthotic appliances that straighten or re-shape a body pan (ncluding cranial banding and some types
of braces). Tubings and masks are not wvered except when used with Durable Medical Equipment as
described in Section I of the COC.
H. Mental Health/Substance Abuse
Services performed m connection with conditions not dazsifmd in the current edition of the
Diagnostic and Statistical Manual of the American Psychiatric Association. Services that extend
beyond the period necessary for short-term evaluation, diagnosis, treatment, or crisis intervention.
Mental Health treatment ofinsomnia and other sleep disorders, neurological disorders, and other
disorders with a known physical basis.
Treatment of conduct and impulse control disorders, personality disorders, paraphilras and other
Mental Illnesses that will not substantially improve beyond the current level of functioning, or that are
not subject to favorable modification or management according to prevailing national standards of
clinical practice, as reasonably determined by the Mental Health/Substance Abuse Designee.
Servrces utilizing methadone treatment as maintenance, L A.A M. (I-Alpha-Acetyl•Methadol),
Cyclazocme, or their equivalents. Treatment provided in connecton with or to comply with
involuntary commitments, police delemions and other similar arrangements, unless authorized 6y the
Mental Health/Substance Abuse Designee Residential treatment services. Services or supplies far the
diagnosis or «eatment of Mental Illness, alcoholism or substance abuse disorders that, in the
reasonable judgment of the Mental Health/Substance Abuse Designee, are any of the (ollowing~ Not
consistent with prevailing national standards o(cbnical practice for the treatment of such conditions.
Not consi stem with prevailing professwnal research demonstrating that the services or supplies will
have a measurable and beneficial health outcome. Typically do not result in outcomes demonstrably
better than other available treatment alternatives that are less intensnve or more cost effectnve. Not
consistent with the Mental Health/Substance Abuse Desgnee's level of care guidelines or best
practices as modified from lime to time The Mental Health/$ubstance Abuse Designee may consult
with pro (essional clinical consultants, peer review committees or other appropriate sources for
recommendations and information regarding whether a service or supply meets any of these criteria
Services for the treatment of mental illness or mental health conditions and substance abuse services
and chemical dependency services that the Enrolling Croup has elected to provide through a separate
benefit plan.
I. Nutrition
Megavitamin and nutrition based therapy; nutritional counseling for either individuals or groups.
Enteral feedings and other nutritional and electrolyte supplements, including infant Cormula and donor
f
breast milk, except az described in Sec«on I of the COC under the heading Pescription and Non-
prcscriprion Emerul Frrmulas.
J. Physical Appearance
Cosmetic Procedures including, but not limited to, pharmacological regimens; nutritional procedures
or treatments; salabrasion, chemosurgery and other such skin abravon procedures associated wish the
removal o(scars, tattoos, and/or which are performed az a treatment for acne Replacement o(an
existing breast implant is excluded if the earlier breast implant was a Cosmetic Procedure.
(Replacement of an existing breast implant is considered reconstruUive if the initial breast implant
followed mastectomy.) Physical conditioning programs such as athletic training, bodybuilding,
exerese, fitness, flexibility, and diversion or general motivation. Weight loss programs for medical
and non-medical reasons Wrgs, regardless of the reason for the hair loss.
K. Providers
Services performed by a provider with your same legal residence or who is a family member by birth
or marriage, including spouse, brother, sister, parent or child. This includes any service the provider
may perform on himsel(or herself Services provided at afree-standing or Hospital-based diagnostic
facility wuhout an order written by a Physician or other provider az further descnbed in Section 2 of
the COC (this exclusion does not apply to mammography testing).
L. Reproduction
Health services and associated expenses for infertility treatments Surrogate parenting. The reversal of
voluntary stenhzation.
M. Services Provided under Another Plan
Health services for which other coverage is required by federal, state or local law to be purchased or
provided through other arrangements, including but not limited to coverage requued by workers'
compensation, no-fault automobile insurance, or similar legislation. If coverage under~workers'
compensation or similar legislation is optional because you could elect it, or could have it elected for
you, Benefits will not be paid for any Injury, Mental Illness or Sickness that would have been covered
under workers'•compensation or similar legislation had that coverage been elected. Health services for
treatment of military service-related disabilities, when you are legally entitled to other coverage and
facilities are reasonably available to you. Health services while on active military duty.
N. Transplants
Health services for organ and tissue «ansplants, except those described in Section I of the COC.
Health services connected with the removal o(an organ or tissue from you for purposes of a transplant
to another person. (Donor costs (or removal are payable Cor a transplant through the organ recipient's
Benefits under the Policy) Health services for transplants involving mechanical or animal organs
Transplant services that are not performed at a Designated Facility Any solid organ transplant that is
performed as a treatment for cancer. Any multiple organ transplant not listed as a Covered Health
Service under the heading Transplantation Servrces in Section 1 of the COC.
O. Travel
Health services provided in a foreign country, unless required as Emergency Health Servrces
Travel or transportation expenses, even though prescribed by a Physician Some travel expenses
related to covered transplantation services may be reimbursed at our discretion.
P. Vision and Hearing
Purchase cost of eye glazses, contact lenses, or hearing aids Fitting charge for hearing aids, eye
glasses or contact lenses. Eye exercise therapy Surgery that is intended to allow you to see better
without glazses or other vision correction including radial keratotomy, lazer, and other refrauive eye
surgery.
Q. Other Exclusions
Health services and suppLes that do not meet the definition of a Covered Health Servme -see
definition rn Section 10 of the COC.
Physical, psychiatric or psychological examinations, testing, vaccinations, immunizations or
«eatments otherwise covered under the Policy, when such services are (I) required solely for
purposes of career, education, sports or camp, travel, employment, insurance, marriage or adoption;
(2) relating to judicial or administrative proceedings or orders, (3) conducted for purposes of medical
research; or (4) to obtain or maintain a Incense o(any type.
Health services received as a result of war or any act of war, whether declared or undeclared or caused
during service m the armed forces of any country
Health services received after the date your coverage under the Policy ends, including health services
for medical conditions ansng prior to the date your coverage under the Policy ends
Health services for which you have no legal responsibility to pay, or for which a charge would not
ordinarily be made in the absence oC coverage under the Policy.
Charges in excess of Eligible Expenses or in excess o(any specified limitation
Services for the evaluation and treatment of temporomandibularjoint syndrome (TMJ), whether the
services are considered to be medical or dental in nature, except as descnbed in Section I of the COC
under the heading Bones or Joints ofihe ./aw and Faaol Region Upper and lowerjawbone surgery
except as required for direct «eatment of acute traumatic Injury or cancer. Onhognathic surgery, jaw
alignment and treatmen( (or the temporomandibularjaint, except az a treatment ofobstructive sleep
apnea.
Surgical treatmentrand non-surgical treatment of obesity (including morbid obesity).
Growth hormone therapy; sex transformation operations, treatment of benign gynecomastia (abnormal
breast enlargement in males), medcal and surgical treatment of excessive sweating (hyperhidrosis);
medical and surgical treatment for snoring, except when provided as part of treatment Cor documemed
obstructive sleep apnea Oral appliances for snoring. Custodial care; domiciliary care; private duty
nursing; respite care, rest cures.
Psychosurgery. Speech therapy except as regwred Cor treatment d(a speech impediment or speech
dysfunction that results from Injury, stroke, cleft lip/cleft palate or Congenital Anomaly.
This summary of Benefits is intended only to highlight your Benefits and shculd not be relied upon to fully determine coverage This plan may not cover all your health care expenses. Please refer to the
Certif care of Coverage for a complete listing of services, limitations, exclusions and a description of all the terms and conditons of coverage If this description conflicts in any way wnh the Certificate of
Coverage, the Certd]cate of Coverage prevails Terms that are capitalized in the Benefit Summary are defined in the Certificate of Coverage.
021_BS_Chc FLNEM01002 NItH 213-1599 1104
YOUR BENEFITS
•
'U~ited~Iealthcare
Choice Plus Plan 061
Choice Plus plan gives you the freedom to see any Physician or other
health care professional from our Network, including specialists,
without a referral. With this plan, you will receive the highest level of
benefits when you seek care from a network physician, facility or other
health care professional. In addition, you do not have to worry about
any claim forms or bills.
You also may choose to seek care outside the Network, without a
referral. However, you should know that care received from anon-
network physician, facility or other health care professional means a
higher deductible and Cop__a~yyment. In addition, if you choose to seek
care outside the Network, UnitedHealthcare only pays a portion of
those charges and it is your responsibility to pay the remainder. This
amount you are re wired to pay, which could be significant, does not
apply to the Out-o~ Pocket Maximum. We recommend that you ask the
non-network physician or health care professional about their billed
charges befoYe you receive caYe.
Some of the Important Benefits
You have access to a Network of
physicians, facilities and other health care
professionals, including specialists, without
designating a Primary Physician or
obtaining a referral.
Benefits are available for office visits and
hospital care, as well as inpatient and
outpatient surgery.
Care CoordinationSM services are available
to help identify and prevent delays in care
for those who might need specialized help.
of Your Plan:
Emergencies are covered anywhere in the
world.
Pap smears are covered.
Prenatal care is covered.
Routine check-ups are covered.
Childhood immunizations are covered.
Mammograms are covered.
Vision and hearing screenings are covered.
FLNGM06102
~~.
Choice Plus Benefits Summary
TYPes of Coverage Network Benefits /Copayment Amounts Non-Network Benefits /Copayment Amounts
This Benefit Summary is intended only to highlight your Annual Deductible: $250 per Covered Person per
• Annual Deductible: $500 per Covered Person per
Benefits and should not be relied upon to fully calendar year, not to exceed 5500 for all Covered calendar year, not to exceed $1,000 for all Covered
determine coverage. This benefit plan may not cover al l Persons in a family. Persons in a family.
of your health care expenses. More complete
descriptions of Benefits and the terms under which Out-of-Pocket Maximum: $2,000 per Covered Person Out-o6Pocket Maximum: $4,000 per Covered Person
they are provided are contained in the Certificate of per calendar year, not to exceed $4,000 for all Covered per calendar year, not to exceed $8,000 for all Covered
Coverage that you will receive upon enrolling in the Persons in a family. The Out-of-Pocket Maximum does Persons in a family. The Out-of-Pocket Maximum does
Plan. not include the Annual Deductible. Copayments for not include the Annual Deductible. Copayments for
If this Benefit Summary conflicts in any way with the some Covered Health Services will never apply to the some Covered Health Services will never apply to the
Policy issued to your employer, the Policy shall prevail . Out-of-Pocket Maximum as specified in Section I ofthe Out-of-Pocket Maximum as specified in Section I ofthe
Terms that are capitalized in the Benefit Summary are COC. COC.
defined in the Certificate of Coverage. Maximum Policy Benefit: No Maximum Policy Maximum Policy Benefit: $1,000,000 per Covered
Where Benefits are subject to day, visit and/or dollar Benefit. Person.
limits, such limits apply to the combined use of Benefits
whether in-Network orout-of-Network, except where
mandated by state law.
Network Benefits are payable for Covered Health
Services provided by or under the direction of your
Network physician.
`Prior Notification is required for certain services.
1. Ambulance Services -Emergency only Ground Transportation: 20% of Eligible Expenses Same as Network Benefit
Air Transportation: 20% of Eligible Expenses
2. Dental Services -Accident only `20% oC Eligible Expenses `Same as Network Benefit
'Prior notification is required before follow-up `Prior notification is required before follow-up
treatment begins. treatment begins.
3. Durable i`ledical Equipment 20% of Eligible Expenses '40% of Eligible Expenses
Network and Nan-Network Benefits for Durable 'Prior notification is required when the cost is more
Medical Equipment are limited to $2,500 per than $1,000.
calendar year. Limits do not apply to Durable
Medical Equipment classified as diabetic equipment
or supplies.
4. Emergency Health Services $100 per visit Same as Network Benefit
`Notification is required if results in an Inpatient Stay.
5. F,ye Examinations $20 per visit 40°./0 of Eligible Expenses
Refractive eye examinations are limited to one Eye Examinations for refractive errors are not covered.
every other calendar year from a Network Provider.
6. Home Health Care 20% of Eligible Expenses `40% of Eligible Expenses
Network and Non-Network Benefits are limited to
60 visits for skilled care services per calendar year
7. Hospice Care 20% of Eligible Expenses `40% of Eligible Expenses
Network and Non•Network Benefits are limited to
360 days during the entire period of time a Covered
Person is covered under the Policy.
8. Hospital -Inpatient Stay 20% of Eligible Expenses `40% of Eligible Expenses
9. Injections Received in a Physician's Office $20 per visit 40% per injection
]0. Maternity Services Same as 8, I1, 12 and l3 Same as 8, l 1, 12 and 13
No Copayment applies to Physician office visits for `Notification is required if Inpatient Stay exceeds 48
prenatal care after the first visit. hours following a normal vaginal delivery or 96 hours
following a cesarean section delivery.
ll. Outpatient Surgery, Diagnostic and Therapeutic
Services
Outpatient Surgery 20% of Eligible Expenses 40% of Eligible Expenses
Outpatient Diagnostic Services For lab and radiology/Xray: No Copayment 40% of Eligible Expenses
Outpatient Diagnostic/Therapeutic Services - CT 20% of Eligible Expenses 40% of Eligible Expenses
Scans, Pet Scans, MRI and Nuclear Medicine
Outpatient Therapeutic Treatments 20%of Eligible Expenses 40%of Eligible Expenses
12. Physician's Office Services
Covered Health Services for preventive medical $20 per visit. No Copayment applies when a Physician No Benefits for preventive care, except Child Health
•
care. charge is not assessed. Supervision Services.
Covered Health Servrces for the diagnosis and 40% of Eligible Expenses
treatment of a Sickness or Injury. 520 per visit. No Copayment applies when a Physician
charge is not assessed.
13. Professional Fees for Surgical and Medical 20%oCEligible Expenses 40%of Eltgible Expenses
Services
~~:;
YOUR BENEFITS
Types of Coverage Network Benefts /Copayment Amounts Non-Network Benefits /Copayment Amounts
14. Prosthetic Devices 20% of Eligible Expenses 40% of Eligible Expenses
Network and Non-Network Benefits for prosthetic
• devices are limited to $2,500 per calendar year.
15. Reconstructive Procedures Same as 8, I1, 12, 13 and 14 *Same as 8, 11, l2, 13 and 14
16. Rehabilitation Services -Outpatient Therapy $20 per visit 40% of Eligible Expenses
Network and Non-Network Benefits are limited as
follows: 20 visits of physical therapy; 20 visits of
occupational therapy; 20 visits of speech therapy; 20
visits of pulmonary rehabilitation; and 36 visits of
cardiac rehabilitation per calendar year.
17. Skilled Nursing Facility/Inpatient Rehabilitation 20°io of Eligible Expenses '40% of Eligible Expenses
Facility Services
Network and Non-Network Benefits are limited to
60 days per calendar year.
18. Transplantation Services •20% of Eligible Expenses '40% of Eligible Expenses
Benefits are limited to $30,000 per transplant.
19. Urgent Care Center Services $50 per visit - 40% of Eligible Expenses
Additional Benefits
Bones or Joints of the Jaw and Facial Region Same as 8, l I, 12 and 13 *40% of Eligible Expenses
Child Health Supervision Services Same as l 1, 12, 13 and l6 Same as 11, 12, 13 and 16
Cleft Lip/Cleft Palate Treatment Same as 8, I I, 12, 13, and ]6 'Same as 8, 11, 12, 13 and I6
Dental Procedures -Anesthesia and Hospitalization Same as 8, l I, and 13 'Same as 8, 11 and 13
Diabetes Treatment Same as 3, 11, 12 and 13 Same as 3, 1 I, 12 and 13
Mammography No Copayment Same as Network Benefit
Mastectomy Same as 8, 1 I, 12 and 13 'Same as 8, 1 I, 12 and 13
Mental Health and Substance Abuse Services - $20 per individual visit; $ I S per group visit. 40% of Eligible Expenses
Outpatient
Must receive prior authorization through the Mental
Health/Substance Abuse Designee. Network and Non-
Network Benefits are limited to 30 visits per calendar
year
Mental Health and Substance Abuse Services - 20%of Eligible Expenses 40% of Eligible Expenses
Inpatient and Intermediate
Must receive prior authorization through the Mental
Health/Substance Abuse Designee. Network and Non-
Network Benefits are limited to 30 days per calendar
year.
Osteoporosis Treatment Same as 11, 12 and 13 Same as 11, 12 and 13
Prescription and Non-Prescription Enteral Formulas 20°io of Eligible Expenses 40% of Eligible Expenses
Benefits (or low protein food products for Covered
Persons through age 24 are limited to $2,500 per
calendar year.
Spinal Treatment $20 per visit 40% of Eligible Expenses
Benefits include diagnosis and related services and are
limited to one visit and treatment per day. Network and
Non-Network Benefits ace limited to 24 visits per
calendar year.
•
L
Exclusions
Except as may be specifically provided in Section I of the Certificate o(Coverage (COC) or through a
-Rider to the Falicy, the following are nut covered.
A. Alternative Treatments
• Acupressure; hypnotism; rolfing; massage theraPY: aromatheraPY; acupuncture: and other forms of
alternative treatment.
B. Comfort or Convenience
Personal comfort or convenience items or services such as television; telephone; barber or beauty
service; guest service; supplies, equipment and similar incidental services and supplies (or personal
comfort including air conditioners, air purifiers and filters, batteries and battery chargers,
dehumidifiers and humidifiers; devices or computers to assist in communication and speech.
C. Dental
Except as specifically described as covered in Section I of the COC under the headings Den1a!
S'ervrces -Accident only and C/efr Lip/Clefs Palote Treatment, dental services are excluded. There is
no coverage for services provided for the prevention, diagnosis, and treatment of the teeth or gums
(including extrattion, restoration, and replacement of teeth and services to improve dental clinical
outcomes) Denial implants and dental braces are excluded Dental z-rays, supplies and appliances and
all associated expenses arising out of such dental services (including hospitalizations and anesthesia)
are excluded, except as might otherwise be required for transplant preparation, tmtiation of
immunosuppressives, the direct treatment of acwe traumatic Injury, cancer, or cleft palate, or as
described in Section I of the COC under the heading o(Denm! Procedures -Anesthesia and
Hoapna(izalmn. Treatment for congenitally missing, malposnioned, or super numerary teeth is
excluded, even if part of a Congenital Anomaly except in connection with cleft lip or cleft palate.
D. Drugs
' Prescription drug products for outpatient use that are filled by a prescription order or refill. Self-
' injectable medications except as described in Section I of the COC under the heading of Diobe/er
Treormenr Non-injectable medications given m a Physician's office except az regtnred in an
' Emergency. Over-the-counter drugs and Treatments
E. Experimental, Investigational or Unproven Services
Experimental, Investigational or Unproven Services are excluded, except (a) bone marrow transplants
and (b) medically appropriate medications prescribed for the treatment of cancer, for a particular
indication, if that drug is recognized for the treatment of that indication m a standard reference
compendium or recommended in medical literature. The fact that an Experimental, Investigational or
Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a
pamcular condition will not result in Benefits if the procedure is considered to be Experimental,
tnvestigahonal or Unproven in the treatment of that particular condition.
F. Foot Care
Routine foot care (including the cutting or removal of corns and calluses); nail trimming, cutting, or
debriding; hygienic and preventive maintenance foot care; treatment of flat feet or subluxation of the
foot, shoe onhotics.
O Medical Supplies and Appliances
Devices used specifically as safety items or to affect performance primarily in sports-related activities.
Prescribed or non-prescribed medical supplies and disposable supplies including but not limited to
elastic stockings, ace bandages, gauze and dressings, ostomy supplies, syringes and diabetic test strips.
Orthotic appliances that straighten or re-shape a body part (including cranial banding and some types
of braces) Tubmgs and masks are not covered except when used with Durable Medical Equipment as
described in Section I of the COC.
II. Mental Health/Substance Abuse
Services performed in connection with conditions not clazsified in the current edition of the
Diagnostic and Statistical Manual o(the American Psychiatric Association. Services that extend
beyond the period necessary for short-term evaluation, diagnosis, treatment, or crisis intervention.
Mental Health treatment of insomnia and other sleep disorders, neurological disorders, and other
disorders with a known physical basis.
Treatment of conduct and impulse control disorders, personality disorders, paraphiliaz and other
A1ental Illnesses that will not substantially improve beyond the current level of functioning, or that are
not subject to Cavorable modification or management according to prevailing national standards of
clinical practice, as reasonably determined by the Mental Health/Substance Abuse Designee.
Services utilizing methadone treatment as maintenance, L.A.A M. (I-Alpha-Acetyl-Methadol),
Cyclazocine, or their equivalents. Treatment provided in connection with or to comply with
involuntary commitments, police detentions and other vmilar arrangements, unless authorized by the
Mental Health/Substance Abuse Designee. Residential treatment services. Services or supplies Cor the
diagnosis or treatment of Mental Illness, alcoholism or substance abuse disorders that, in the
reasonable judgment oC the Mental Health/Substartce Abuse Designee, are any o(the following Not
consistent with prevailing national standards of clinical practice for the treatment of such conditions
Not consistent with prevailing professional research demonstrating that the services or supplies will
have a measurable and beneficial health outcome Typically do not result in outcomes demonstrably
better than other available treatment alternatives that are less intensive or more cost effective. Not
consistent with the Mental Health/Substance Abuse Designee's level of care guidelines or best
practices as modified from time to time The Mental Health/Substance Abuse Designee may consult
with professional clinical consultants, peer review committees or other appropriate sources for
recommendations and information regarding whether a service or supply meets any of these criteria
Services for the treatment of mental illness or mental health conditions and substance abuse services
and chemical dependency services that the Enrolling Group has elected to provide through a separate
benefit plan.
I. Nutrition
Megavitamin and nutrition based therapy; nutritional counseling (or either individuals or groups.
Enteral feedings and other nutritional and electrolyte supplements, including infant formula and donor .
~~
~~
United Healthcare Insurance Company
breast milk, except az described in Section 1 0(the COC under the heading Pre.rcripuon and Non-
prescrrplion enteral Formulas.
J. Physical -Appearance
Cosmetic Procedures including, but not limited to, pharmacological regimens; nutritional procedures
or treatments; salabrazion, chemosurgery and other such skin abrasion procedures associated with the
removal of scars, tattoos, and/or which are performed as a treatment for acne. Replacement of an
existing breast implant is excluded if the earGei breast implant was a Cosmetic Procedure.
(Replacement of an existing breast implant is considered reconstructive if the initial breast implant
followed mastectomy.) Physical conditioning programs such az athletic training, bodybuilding,
exercise, fitness, flexibility, and diversion or general motivation. Weight loss programs for medical
and non-medical reasons. Wigs, regardless of the reason for the hair loss.
K. Providers
Services performed by a provider with your same legal residence or who is a family member by birth
or marriage, including spouse, brother, sister, parent or child. This includes any service the provider
may perform on himself or herself Services provided at afree-standing or Hospital-based diagnostic
facility without an order written by a Physician or other provider as further described in Section 2 of
the COC (this exclusion does not apply to mammography testing)
L. Reproduction
Health services and associated expenses for infertility treatments. Surrogate parenting. The reversal of
voluntary stets hzauon.
M. Services Provided under Another Plan
Health services Cor which other coverage is required by federal, state or local law to be purchased or
provided through other arrangements, including but not limited to coverage required by workers'
compensation, no-fault automobile insurance, or similar legislation. If coverage under workers'
compensation or similar legislation is optional because you could dect n, or could have it dotted for
you, Benef is will not he paid for any Injury, Mental Illness or Sickness that would have been covered
under workers' compensation or similar legislation had that coverage been elected. Health services (or
treatment of military service-related disabilities, when you are legally entitled to other coverage and
(acs Mies are reasonably available to you. Health services while on active military duty.
N. Transplants
Health services for organ or tissue transplants are excluded, except those specified as covered in
Section I oCthe COC. Any solid organ transplant that is performed as a treatment Cor cancer. Health
services connected with the removal of an organ or tissue from you for purposes of a transplant to
another person Health services for transplants involving mechanical or animal organs Any multiple
organ vansplant not listed as a Covered Health Service in Section 1 of the COC.
O. Travel
Health services provided in a foreign country, unless required as Emergency Health Services.
Travel or transportation expenses, even though prescribed by a Physician Some travel expenses
related to covered transplantation services may be reimbursed at our discretion.
P. Vision and Hearing
Purchase cost oCeye glasses, contact lenses, or hearing aids. Fitting charge (or hearing aids, eye
glasses or contact lenses. Eye exercise therapy Surgery that is intended to allow you to see better
without glasses or other vision correction mdudmg radial keratotomy, laser, and other refractive eye
surgery
Q. Other Exclusions
Health services and supplies that do not meet the definition of a Covered Health Service -see
definition in Section 10 of the COC.
Physical, psychiatric or psychological examinations, testing, vaccinations, immunizations or
treatments otherwise covered under the Policy, when such services are: (I) required solely for
purposes of career, education, sports ar camp, travel, employment, insurance, marriage or adoption,
(2) relating to judicial or administrative proceedings or orders; (3) conducted for purposes of medical
research; or (4) to obtain or maintain a license of any type.
Health services received az a result of war or any act of war, whether declared or undeclared or caused
during service in the armed forces oCany country.
Health services received after the date your coverage under the Policy ends, including health services
(or medical condnions arising poor to the date your coverage under the Policy ends
Health services for which you have no legal responsibility to pay, or for which a charge would not
ordinarily be made in the absence of coverage under the Policy. In the event that aNon-Network
provider waives Copayments and/or the Annual Deductible for a particular health service, no Benefits
are provided for the health service for which Copayments and/or the Annual Deductible are waived.
Charges in excess oC Eligible Expenses or m excess of any specified limitation.
Services for the evaluation and treatment o(temporomandibular loin[ syndrome (TMJ), whether the
services are considered to be medical or denial in nature, except az described in Section I of the COC
under the heading Rnnes or Jornrr njrhe Jaw and I'ociaf Regran. Upper and lower jawbone surgery
except az required Cor direct treatment of acute traumatic Injury or cancer. Orthognathic surgery, jaw
alignment and treatment (or the temporomandibular joint, except as a treatment of obstructive sleep
apnea.
Surgical treatment and non-surgical treatment of obesity (including morbid obesity)
Growth hormone therapy, sex transformation operations; treatmem of benign gynecomastia (abnormal
breast enlargement in males), medical and surgical treatment of excessive sweating (hyperhidrosis),
medical and surgical treatment for snoring, except when provided as part of treatment for documented
obstructive sleep apnea. Oral appliances (or snoring Custodial care; domiciliary care, private duty
nursing, respite care; rest cures.
Psychosurgery. Speech therapy except as required for treatment of a speech impediment or speech
dysfunction that results from Injury, stroke, cleft lip/cleft palate or Congenital Anomaly
Th;s summary o(Benefits is intended only to highlight your Benefits and should not be retied upon to fully determine coverage This plan may not cover ail your health care expenses Please refer to the
CentOcate of Coverage for a complete listing oCservices, limitations, exclusions and a description of all the terms and condnions of coverage. If this description conflicts in any way with the Certificate oC
Coverage, the Certificate of Coverage prevails. Terms that are capitalized in the Benefit Summary are defined in the Cemf tale of Coverage.
021_BS_ChcPls FLNGM06102 WLG 213-1637 1104
YOUR BENEFITS
UnitedHealthcare
• Pharmacy Management Program Plan 001
UnitedHealthcare's pharmacy management program provides
clinical pharmacy services that promote choice, accessibility and
value. The program offers a broad network of pharmacies (more
than 56,000 nationwide) to provide convenient access to
medications.
While most pharmacies participate in our network, you should
check first. Call your pharmacist or visit our online pharmacy
service at www.myuhc.com. The online service offers you home
delivery of prescriptions, ability to view personal benefit
coverage, access health and well being information, and even
location of network retail neighborhood pharmacies by zip code.
Copayment per Prescription Order or Refill
Your Copayment is determined by. the tier to which the Prescription Drug List Management Committee has assigned the Prescription
Drug Product. All Prescription Drug Products on the Prescription Drug List are assigned to Tier 1, Tier 2 or Tier 3. Please access
www.myuhc.com through the Internet, or call the Customer Service number on your ID card to determine tier status.
For a single Copayment, you may receive a Prescription Drug Product up to the stated supply ]imit. Some products are subject to
additional supply limits. You are responsible for paying the lower of the applicable Copayment or the retail Network Pharmacy's Usual
and Customary Charge, or the lower of the applicable Copayment or the Home Delivery Pharmacy's Prescription Drug Cost.
Also note that some Prescription Drug Products require that you notify us in advance to determine whether the Prescription Drug
Product meets the definition of a Covered Health Service and is not Experimental, Investigational or Unproven.
Retail Network Home Delivery Network
Pharmacy Pharmacy
For up to a 31 day supply For up to a 90 day supply
Tier 1 $7 $17.50
Tier 2 $25 $62.50
Tier 3 $40 $100
r
~~
FLNPP00104
Af
United Healthcare Insurance Company
Other Important Cost Sharing Information
Annual Drug
Deductible
No Annual Drug Deductible
Out-of-Pocket Drug
No Out-of-Pocket Drug Maximum
Maximum
Exclusions
Exclusions from coverage listed in the Certificate apply also to 1his.Rider.
In addition, the following exclusions apply: '
Outpatient Prescription Drug Products obtained from anon-Network
Pharmacy.
Durable Medical Equipment. Prescribed and non-prescribed outpatient
supplies, other than the diabetic supplies and inhaler spacers specifically
stated as covered.
General vitamins, except the following which require a Prescription
Coverage for Prescription Drug Products for the amount dispensed (days Order or Refill: prenatal vitamins, vitamins with fluoride, and single
supply or quantity limit) which exceeds the supply limit. entity vitamins.
Prescription Drug Products dispensed outside the United States, except as Unit dose packaging of Prescription Drug Products.
required for Emergency treatment. Medications used for cosmetic purposes.
Drugs which are prescribed, dispensed or intended for use while you are
an inpatient in a Hospital, Skilled Nursing Facility, or Alternate Facility.
Experimental, Investigational or Unproven Services and medications;
medications used for experimental indications and/or dosage regimens
determined by us to be experimental, investigational or unproven.
Prescription-Drug Products furnished by the local, state or federal
government. Any Prescription Drug Product to the extent payment or
benefits are provided or available from the local, state or federal
government (for example, Medicare) whether or not payment or benefits
are received, except as otherwise provided by law.
Prescription Drug Products for any condition, Injury, Sickness or mental
illness arising out of, or in the course of, employment for which benefits
are available under any workers' compensation law or other similar laws,
whether or not a claim for such benefits is made or payment or benefits
are received.
Any product dispensed for the purpose of appetite suppression and other
weight loss products.
A specialty medication Prescription Drug Product (such as
immunizations and allergy serum) which, due to its characteristics as
determined by us, must typically be administered or supervised by a
qualified provider or licensed certified health professional in an
outpatient setting. This exclusion does not apply to Depo Provera and
other injectable drugs used for contraception.
~J
J
Prescription Drug Products, including New Prescription Drug Products or
new dosage forms, that are determined to not be a Covered Health
Service.
Prescription Drug Products as a replacement for a previously dispensed
Prescription Drug Product that was lost, stolen, broken or destroyed.
Prescription Drug Products when prescribed to treat infertility.
Drugs available over-the-counter that do not require a Prescription Order
or Refill by federal or state law before being dispensed. Any Prescription
Drug Product that is therapeutically equivalent to an over-the-counter
drug. Prescription Drug Products that are comprised of components that
are available in over-the-counter form or equivalent.
Prescription Drug Products for smoking cessation.
Compounded drugs that do not contain at least one ingredient that
requires a Prescription Order or Refill. Compounded drugs that contain at
least one ingredient that requires a Prescription Order or Refill are
assigned to Tier 3.
New Prescription Drug Products and/or new dosage forms until the date
they are reviewed by our Prescription Drug List Management Committee.
Growth hormone therapy for children with familial short stature (short
stature based upon heredity and not caused by a diagnosed medical
condition).
This summary or Benefits is intended only to highlight your Benefits for outpatient Prescnption Drug Products and should not be retied upon to determine coverage Your plan may not cover all your outpatient
prescription drug expenses Please refer to your Outpatient Prescription Drug Rider and the Certificate of Coverage fbr a complete listing or services, limitations, exclusions and a descnption o(all the terms and
conditions ofcoverage [f this descnption conflicts in any way with the Outpatient Prescription Drug Rider or the Cen~ficate or Coverage, the Outpat~enl Prescnpnon Drug Rider and Certificate or Coverage
prevail. Capitalized terms in the Benefit Summary are defined m the Outpatient Prescription Drug Rider and!or Certificate or Coverage.
041_BS_RX_NET FLNPP00104 K7 213-1355 0804
.,.
YOUR BENEFITS
LnitedHealthcare
PhaYmacy Management Program Plan OOI
UnitedHealthcare's pharmacy management program provides
clinical pharmacy services that promote choice, accessibility and
value. The program offers a broad network of pharmacies (more
than 56,000 nationwide) to provide convenient access to
medications.
While most pharmacies participate in our network, you should
check first. Call your pharmacist or visit our online pharmacy
service at www.myuhc.com. The online service offers you home
delivery of prescriptions, ability to view personal benefit
coverage, access health and well being information, and even
location of network retail neighborhood pharmacies by zip code.
Copayment per Prescription Order or Refill
Your Copayment is determined by the tier to which the Prescription Drug List Management Committee has assigned the Prescription
Drug Product. All Prescription Drug Products on the Prescription Drug List are assigned to Tier I, Tier 2 or Tier 3. Please access
www.m~uhc.com through the Internet, or call the Customer Service number on your ID card to determine tier status.
For a single Copayment, you may receive a Prescription Drug Product up to the stated supply limit. Some products are subject to
additional supply limits. You are responsible for paying the lower of the applicable Copayment or the retail Network Pharmacy's Usual
and Customary Charge, or the lower of the applicable Copayment or the Home Delivery Pharmacy's Prescription Drug Cost.
Also note that some Prescription Drug Products require that you notify us in advance to determine whether the Prescription Drug
Product meets the definition of a Covered Health Service and is not Experimental, Investigational or Unproven.
Retail Network Home Delivery Network Retail Non-Network
Pharmacy Pharmacy Pharmacy
For up to a 31 day supply For up to a 90 day supply For up to a 31 day supply
Tier 1 $7 $17.50 $7
Tier 2 $25 $62.50 $25
Tier 3 $ao $100 $40
C
F L NR P00 104
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United Healthcare Insurance Company
®ther Important Cost Sharing information
NOTE: If you purchase a Prescription Drug Product from aNon-Network Pharmacy, you are responsible for any difference between what the Non-
Ne[work Pharmacy charges and the amount we would have paid for the same Prescription Drug Product dispensed by a Network Pharmacy.
Annual Drug
Deductible No Annual Drug Deductible
Out-of-Pocket Drug
No Out-of-Pocket Drug Maximum
Maximum
Exclusions
Exclusions from coverage listed in the Certificate apply also to this Rider.
In addition, the following exclusions apply:
Coverage for Prescription Drug Products for the amount dispensed (days
supply or quantity limit) which exceeds the supply limit.
Durable Medical Equipment. Prescribed and non-prescribed outpatient
supplies, other than the diabetic supplies and inhaler spacers specifically
stated as covered.
General vitamins, except the following which require a Prescription
Prescription Drug Products dispensed outside the United States, except as Order or Refill: prenatal vitamins, vitamins with fluoride, and single
required for Emergency treatment. entity vitamins.
Drugs which are prescribed, dispensed or intended for use while you are
an inpatient in a Hospital, Skilled Nursing Facility, or Alternate Facility.
Experimental, Investigational or Unproven Services and medications;
medications used for experimental indications and/or dosage regimens
determined by us to be experimental, investigational or unproven.
Prescription Drug Products furnished by the local, state or federal
government. Any Prescription Drug Product to the extent payment or
benefits are provided or available from the local, state or federal
government (for example, Medicare) whether or not payment or benefits
are received, except as otherwise provided by law.
Prescription Drug Products for any condition, Injury, Sickness or mental
illness arising out of, or in the course of, employment for which benefits
are available under any workers' compensation law or other similar laws,
whether or not a claim for such benefits is made or payment or benefits
are received.
Unit dose packaging of Prescription Drug Products.
Medications used for cosmetic purposes.
Prescription Drug Products, including New Prescription Drug Products or
new dosage forms, that are determined to not be a Covered Health
Service.
Prescription Drug Products as a replacement for a previously dispensed
Prescription Drug Product that was lost, stolen, broken or destroyed.
Prescription Drug Products when prescribed to treat infertility.
Drugs available over-the-counter that do not require a Prescription Order
or Refill by federal or state law before being dispensed. Any Prescription
Drug Product that is therapeutically equivalent to an over-the-counter
drug. Prescription Drug Products that are comprised of components that
are available in over-the-counter form or equivalent.
Prescription Drug Products for smoking cessation.
Any product dispensed for the purpose of appetite suppression and other
weight loss products.
A specialty medication Prescription Drug Product (such as
immunizations and allergy serum) which, due to its characteristics as
determined by us, must typically be administered or supervised by a
qualified provider or licensed/certified health professional in an
outpatient setting. This exclusion does not apply to Depo Provers and
other injectable drugs used for contraception.
C7
Compounded drugs that do not contain at least one ingredient that
requires a Prescription Order or Refill. Compounded drugs that contain at
least one ingredient that requires a Prescription Order or Refill are
assigned to Tier 3.
New Prescription Drug Products and/or new dosage forms until the date
they are reviewed by our Prescription Drug List Management Committee.
Grov<~th hormone therapy for children with familial short stature (short
stature based upon heredity and not caused by a diagnosed medical
condition).
This summary of Benefits is intended only to highlight your Benefits for outpatient Prescnpuon Drug Products and should not be relied upon to determine coverage Your plan may not cover all your outpahenl
prescription drug expenses Please refer to your Outpauem Prescription Drug Rider and the Certificate o(Coverage for a complete fisting of services, limrtahons, exclusions and a description of all the terms and
conditions of coverage ff this description conftmts in any way wrth the Outpatient Prescription Drug Rider or the Certificate of Coverage, the Outpatient Prescription Drug Rtder and Certificate of Coverage
prevail. Capitalized terms in the Benefit Summary are defined rn the Outpatient Prescription Drug Rider and/or Certificate o(Coverage.
04[_BS_RX_PLS FLNRP00104 K7 213-1304 0804