UnitedHealthcare Insurance Company UnitedHealthcare Choice Plus

UnitedHealthcare

Insurance

Company

UnitedHealthcare

Choice

Plus

Certificate of Coverage, Riders, Amendments, and Notices

for

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Group Number: GA

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Health Plan: 23 - W Prescription Code: OB

Effective Date:

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Offered and Underwritten by

UnitedHealthcare Insurance Company

Riders, Amendments, and

Notices

begin immediately following the last

page

of the Certificate of

Coverage

CCOV.I.11.WI

UnitedHealthcare Insurance

Company

185 Asylum

Street

Hartford, CT

06103-3408

1-800-357-1371

Please read the copy of your enrollment form accompanying this certificate or which

has been otherwise previously delivered to you by us or your employer. Omissions or

misstatements in the enrollment form could cause an otherwise valid claim to be

denied. Carefully check the enrollment form and write us within 10 days if any

information shown on the enrollment form is not correct. The insurance coverage was

issued on the basis that the answers to all questions and any other material information

shown on the enrollment form were correct and complete.

Coverage of Eligible Expenses for Covered Health Services provided by non-Network

providers is limited to the amount we determine solely in accordance with our

reimbursement guidelines as defined in Section 9 of this certificate. We calculate

Eligible Expenses based on available data resources of competitive fees in specific

geographic areas. Eligible Expenses must not be greater than the fees that the

non-Network provider would charge any other health plan in the same or similar

situation for the same services. You are responsible for paying any difference between

the amount the non-Network provider bills you and the amount we will pay for Eligible

Expenses. You may call Customer Care at the telephone number listed on your ID card.

LIMITED BENEFITS WILL BE PAID WHEN NONPARTICIPATING PROVIDERS ARE USED.

You should be aware that when you elect to utilize the services of a nonparticipating

provider for a Covered Health Service, benefit payments to such nonparticipating

provider are not based upon the amount billed. The basis of your benefit payment will

be determined according to the Policy’s fee schedule, usual and customary charge

(which is determined by comparing charges for similar services adjusted to the

geographical area where the services are performed), or other method as defined in the

Policy. YOU RISK PAYING MORE THAN THE COINSURANCE, DEDUCTIBLE AND

COPAYMENT AMOUNT AFTER THE PLAN HAS PAID ITS REQUIRED PORTION.

Nonparticipating providers may bill Covered Persons for any amount up to the billed

charge after the plan has paid its portion of the bill. Participating providers have agreed

to accept discounted payment for Covered Health Services with no additional billing to

the Covered Person other than copayment, coinsurance and deductible amounts. You

may obtain further information about the participating status of professional providers

and information on out-of-pocket expenses by calling the number on your identification

(ID) card or by going to www.myuhc.com.

COC.I.11.WI

1

Certificate of

Coverage

UnitedHealthcare Insurance

Company

Certificate of Coverage is Part of Policy

This Certificate of Coverage (Certificate) is part of the Policy that is a legal document between

UnitedHealthcare

Insurance Company and the Enrolling Group to provide Benefits to Covered Persons, subject to the

terms,

conditions, exclusions and limitations of the Policy. We issue the Policy based on the Enrolling

Group’s

application and payment of the required Policy

Charges.

In addition to this

Certificate

the Policy

includes:

The Group Policy.

The Schedule of Benefits.

The Enrolling Group’s

application.

Riders.

Amendments.

You can review the Policy at the office of the Enrolling Group during regular business hours.

Changes to the Document

We may from time to time modify this Certificate by attaching legal documents called Riders and/or

Amendments

that may change certain provisions of this

Certificate.

When that happens we will send you a new

Certificate,

Rider

or Amendment

pages.

No one can make any changes to the Policy unless those changes are in

writing.

Other Information You Should Have

We have the right to change, interpret, modify, withdraw or add Benefits, or to terminate the Policy, as

permitted

by law, without your

approval.

On its effective date, this Certificate replaces and overrules any Certificate that we may have previously issued

to

you. This

Certificate

will in turn be overruled by any

Certificate

we issue to you in the

future.

The Policy will take effect on the date specified in the Policy. Coverage under the Policy will begin at 12:01

a.m.

and end at 12:00 midnight in the time zone of the Enrolling Group’s location. The Policy will remain in effect

as

long as the Policy Charges are paid when they are due, subject to termination of the

Policy.

We are delivering the Policy in the State of Wisconsin. The Policy is governed by ERISA unless the Enrolling

Group is not an employee welfare benefit plan as defined by ERISA. To the extent that state law applies, the laws

of the State of Wisconsin are the laws that govern the Policy.

COC.I.11.WI

2

Introduction to Your

Certificate

We are pleased to provide you with this

Certificate.

This

Certificate

and the other Policy documents describe your

Benefits, as well as your rights and responsibilities, under the Policy.

How to Use this Document

We encourage you to read your

Certificate

and any attached Riders and/or Amendments

carefully.

We especially encourage you to review the Benefit limitations of this Certificate by reading the attached Schedule

of Benefits

along with Section 1: Covered Health Services and Section 2: Exclusions and

Limitations.

You

should

also carefully read Section 8: General Legal Provisions to better understand how this

Certificate

and your

Benefits

work. You should call us if you have questions about the limits of the coverage available to

you.

Many of the sections of this Certificate are related to other sections of the document. You may not have all of

the

information you need by reading just one section. We also encourage you to keep your Certificate and Schedule

of Benefits

and any attachments in a safe place for your future

reference.

If there is a conflict between this Certificate and any summaries provided to you by the Enrolling Group,

this

Certificate

will

control.

Please be aware that your Physician is not responsible for knowing or communicating your

Benefits.

Information about Defined Terms

Because this Certificate is part of a legal document, we want to give you information about the document that will

help you understand it. Certain capitalized words have special meanings. We have defined these words in Section

9: Defined Terms. You can refer to Section 9: Defined Terms as you read this document to have a clearer

understanding of your Certificate.

When we use the words "we," "us," and "our" in this document, we are referring to UnitedHealthcare Insurance

Company. When we use the words "you" and "your," we are referring to people who are Covered Persons, as that

term is defined in Section 9: Defined Terms.

Don’t Hesitate to Contact Us

Throughout the document you will find statements that encourage you to contact us for further

information.

Whenever you have a question or concern regarding your Benefits, please call us using the telephone number

for

Customer Care listed on your ID card. It will be our pleasure to assist

you.

COC.I.11.WI

3

Your

Responsibilities

Be Enrolled and Pay Required Contributions

Benefits are available to you only if you are enrolled for coverage under the Policy. Your enrollment options,

and

the corresponding dates that coverage begins, are listed in Section 3: When Coverage Begins. To be enrolled

with

us and receive Benefits, both of the following

apply:

Your enrollment must be in accordance with the Policy issued to your Enrolling Group, including the

eligibility requirements.

You must qualify as a Subscriber or his or her Dependent as those terms are defined in Section 9: Defined

Terms.

Your Enrolling Group may require you to make certain payments to them, in order for you to remain enrolled

under the Policy and receive Benefits. If you have questions about this, contact your Enrolling Group.

Be Aware this Benefit Plan Does Not Pay for All Health Services

Your right to Benefits is limited to Covered Health Services. The extent of this Benefit plan’s payments for Covered

Health Services and any obligation that you may have to pay for a portion of the cost of those Covered

Health

Services is set forth in the Schedule of Benefits.

Decide What Services You Should Receive

Care decisions are between you and your Physicians. We do not make decisions about the kind of care

you

should or should not

receive.

Choose Your Physician

It is your responsibility to select the health care professionals who will deliver care to you. We arrange for

Physicians and other health care professionals and facilities to participate in a Network. Our credentialing

process confirms public information about the professionals’ and facilities’ licenses and other credentials, but

does not assure the quality of their services. These professionals and facilities are independent practitioners and

entities that are solely responsible for the care they deliver.

Obtain Prior Authorization

Some Covered Health Services require prior authorization. In general, Physicians and other health

care

professionals who participate in a Network are responsible for obtaining prior authorization. However, if

you

choose to receive Covered Health Services from a non-Network provider, you are responsible for obtaining

prior

authorization before you receive the services. For detailed information on the Covered Health Services

that

require prior authorization, please refer to the Schedule of Benefits.

Pay Your Share

You must pay a Copayment and/or Coinsurance for most Covered Health Services. These payments are due at

the time of service or when billed by the Physician, provider or facility. Copayment and Coinsurance amounts are

listed in the Schedule of Benefits. You must also pay any amount that exceeds Eligible Expenses.

Pay the Cost of Excluded Services

You must pay the cost of all excluded services and items. Review Section 2: Exclusions and

Limitations

to

become

familiar with this Benefit plan’s

exclusions.

COC.I.11.WI

4

Show Your ID Card

You should show your identification (ID) card every time you request health services. If you do not show your

ID

card, the provider may fail to bill the correct entity for the services delivered, and any resulting delay may

mean

that you will be unable to collect any Benefits otherwise owed to

you.

File Claims with Complete and Accurate Information

When you receive Covered Health Services from a non-Network provider, you are responsible for requesting

payment from us. You must file the claim in a format that contains all of the

informatio

n we require, as described

in Section 5: How to File a Claim.

Use Your Prior Health Care Coverage

If you have prior coverage that, as required by state law, extends benefits for a particular condition or a disability,

we will not pay Benefits for health services for that condition or disability until the prior coverage ends. We will pay

Benefits as of the day your coverage begins under this Benefit plan for all other Covered Health Services that are

not related to the condition or disability for which you have other coverage.

COC.I.11.WI

5

Determine Benefits

Our Responsibilities

We make administrative decisions regarding whether this Benefit plan will pay for any portion of the cost of

a

health care service you intend to receive or have received. Our decisions are for payment purposes only. We

do

not make decisions about the kind of care you should or should not receive. You and your providers must

make

those treatment

decisions.

We have the discretion to do the

following:

Interpret Benefits and the other terms, limitations and exclusions set out in this Certificate, the Schedule of

Benefits and any Riders and/or Amendments.

Make factual determinations relating to Benefits.

We may delegate this discretionary authority to other persons or entities that may provide administrative services

for this Benefit plan, such as claims processing. The identity of the service providers and the nature of their

services may be changed from time to time in our discretion. In order to receive Benefits, you must cooperate

with those service providers.

Pay for Our Portion of the Cost of Covered Health Services

We pay Benefits for Covered Health Services as described in Section 1: Covered Health Services and in

the

Schedule of Benefits, unless the service is excluded in Section 2: Exclusions and

Limitations.

This means we

only

pay our portion of the cost of Covered Health Services. It also means that not all of the health care services

you

receive may be paid for (in full or in part) by this Benefit

plan.

Pay Network Providers

It is the responsibility of Network Physicians and facilities to file for payment from us. When you receive

Covered

Health Services from Network providers, you do not have to submit a claim to

us.

Pay for Covered Health Services Provided by Non-Network Providers

In accordance with any state prompt pay requirements, we will pay Benefits after we receive your request for

payment that includes all required information. See Section 5: How to File a Claim.

Review and Determine Benefits in Accordance with our Reimbursement

Policies

We develop our reimbursement policy guidelines, in our sole discretion, in accordance with one or more of

the

following methodologies:

As indicated in the most recent edition of the Current Procedural Terminology (CPT), a publication of

the

American Medical

Association,

and/or the Centers for Medicare and Medicaid Services (CMS).

As reported by generally recognized professionals or

publications.

As

used for Medicare.

As determined by medical staff and outside medical consultants pursuant to other appropriate sources

or

determinations that we

accept.

Following evaluation and validation of certain provider billings (e.g., error, abuse and fraud reviews),

our

reimbursement policies are applied to provider billings. We share our reimbursement policies with Physicians

and

other providers in our Network through our provider website. Network Physicians and providers may not bill you

for the difference between their contract rate (as may be modified by our reimbursement policies) and the billed

charge. However, non-Network providers are not subject to this prohibition, and may bill you for any amounts we

do not pay, including amounts that are denied because one of our reimbursement policies does not reimburse (in

whole or in part) for the service billed. You may obtain copies of our reimbursement policies for yourself or to

COC.I.11.WI

6

share with your non-Network Physician or provider by going to www.myuhc.com or by calling Customer Care at

the telephone number on your ID card.

Offer Health Education Services to You

From time to time, we may provide you with access to information about additional services that are available

to

you, such as disease management programs, health education and patient advocacy. It is solely your

decision

whether to participate in the programs, but we recommend that you discuss them with your

Physician.

COC.I.11.WI

7

Certificate of Coverage Table of

Contents

Section 1: Covered Health Services ........................................................ 8

Section 2: Exclusions and Limitations ................................................. 23

Section 3: When Coverage Begins ........................................................ 34

Section 4: When Coverage Ends ........................................................... 37

Section 5: How to File a Claim ............................................................... 40

Section 6: Questions, Complaints and Grievances ............................. 42

Section 7: Coordination of Benefits ...................................................... 45

Section 8: General Legal Provisions ..................................................... 49

Section 9: Defined Terms ....................................................................... 55

COC.I.11.WI

8

Section 1: Covered Health

Services

Benefits for Covered Health Services

Benefits are available only if all of the following are

true:

The health care service, supply or Pharmaceutical Product is only a Covered Health Service if it is Medically

Necessary. (See definitions of Medically Necessary and Covered Health Service in Section 9: Defined Terms.)

The fact that a Physician or other provider has performed or prescribed a procedure or treatment, or the fact

that it may be the only available treatment for a Sickness, Injury, Mental Illness, substance use disorder,

disease or its symptoms does not mean that the procedure or treatment is a Covered Health Service under

the Policy.

Covered Health Services are received while the Policy is in effect.

Covered Health Services are received prior to the date that any of the individual termination conditions

listed

in

Section 4: When Coverage Ends

occurs.

The person who receives Covered Health Services is a Covered Person and meets all eligibility requirements

specified in the Policy.

This section describes Covered Health Services for which Benefits are available. Please refer to the attached

Schedule of Benefits

for details

about:

The amount you must pay for these Covered Health Services (including any Annual Deductible, Copayment

and/or Coinsurance).

Any limit that applies to these Covered Health Services (including visit, day and dollar limits on

services).

Any

limit that applies to the amount you are required to pay in a year (Out-of-Pocke t

Maximum).

Any responsibility you have for obtaining prior authorization or notifying us.

Please note that in listing services or examples, when we say "this includes," it is not our intent to limit the

description to that specific list. When we do intend to limit a list of services or examples, we state

specifically that the list "is limited to."

1. Ambulance Services

Emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance) to the

nearest Hospital where Emergency Health Services can be performed.

Non-Emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance, as

we determine appropriate) between facilities when the transport is any of the following:

From a non-Network Hospital to a Network

Hospital.

To a Hospital that provides a higher level of care that was not available at the original

Hospital.

To

a more cost-effective acute care

facility.

From an acute facility to a sub-acute setting.

2. Clinical Trials

Routine patient care costs incurred during participation in a qualifying clinical trial for the treatment of:

Cancer.

Cardiovascular disease

(cardiac/stroke).

Surgical musculoskeletal disorders of the spine, hip and knees.

Other diseases or disorders for which, as we determine, a clinical trial meets the qualifying clinical trial

criteria stated below.

Benefits include the reasonable and necessary items and services used to diagnose and treat complications

arising from participation in a qualifying clinical trial.

COC.I.11.WI

9

Benefits are available only when the Covered Person is clinically eligible for participation in the clinical trial as

defined by the researcher. Benefits are not available for preventive clinical trials.

Routine patient care costs for clinical trials include:

Covered Health Services for which Benefits are typically provided absent a clinical trial.

Covered Health Services required solely for the provision of the Investigational item or service, the

clinically

appropriate monitoring of the effects of the item or service, or the prevention of

complications.

Covered Health Services needed for reasonable and necessary care arising from the provision of an

Investigational item or service.

Routine costs for clinical trials do not include:

The Experimental or Investigational Service or item. The only exceptions to this are:

Certain Category B devices.

Certain promising interventions for patients with terminal illnesses.

Other items and services that meet specified criteria in accordance with our medical and drug policies.

Items and services provided solely to satisfy data collection and analysis needs and that are not used in

the

direct

clinical management of the

patient.

Items and services provided by the research sponsors free of charge for any person enrolled in the trial.

To

be a qualifying clinical trial, a clinical trial must meet all of the following

criteria:

Be sponsored and provided by a cancer center that has been designated by the National Cancer Institute

(NCI) as a

Clinical

Cancer Center or

Comprehensive

Cancer Center or be sponsored by any of the following:

National Institutes

of Health (NIH). (Includes

National

Cancer

Institute

(NCI).)

Centers for Disease Control and Prevention (CDC).

Agency for

Healthcare

Research and Quality (AHRQ).

Centers for Medicare and Medicaid Services (CMS).

Department

of Defense (DOD).

Veterans

Administration

(VA).

The clinical trial must have a written protocol that describes a scientifically sound study and have

been

approved by all relevant institutional review boards (IRBs) before participants are enrolled in the trial.

We

may, at any time, request documentation about the

trial.

The subject or purpose of the trial must be the evaluation of an item or service that meets the definition of

a

Covered Health Service and is not otherwise excluded under the

Policy.

3. Congenital Heart Disease Surgeries

Congenital heart disease (CHD) surgeries which are ordered by a Physician. CHD surgical procedures

include

surgeries to treat conditions such as coarctation of the aorta, aortic stenosis, tetralogy of fallot, transposition

of

the great vessels and hypoplastic left or right heart

syndrome.

Benefits under this section include the facility charge and the charge for supplies and equipment. Benefits

for

Physician services are described under

Physician Fees for Surgical and Medical Services.

Surgery may be performed as open or closed surgical procedures or may be performed through

interventional

cardiac

catheterization.

We have specific guidelines regarding Benefits for CHD services. Contact us at the telephone number on your

ID

card for information about these

guidelines.

COC.I.11.WI

10

4. Dental Services - Accident Only

Dental services when all of the following are true:

Treatment is necessary because of accidental damage.

Dental services are received from a Doctor of Dental Surgery or Doctor of Medical

Dentistry.

The dental damage is severe enough that initial contact with a Physician or dentist occurred within 72 hours

of the accident. (You may request an extension of this time period provided that you do so within 60 days of

the Injury and if extenuating circumstances exist due to the severity of the Injury.)

Please note that dental damage that occurs as a result of normal activities of daily living or extraordinary use of

the teeth is not considered having occurred as an accident. Benefits are not available for repairs to teeth that are

damaged as a result of such activities.

Dental services to repair damage caused by accidental Injury must conform to the following time-frames:

Treatment is started within three months of the accident, unless extenuating circumstances exist (such as

prolonged hospitalization or the presence of fixation wires from fracture care).

Treatment must be completed within 12 months of the

accident.

Benefits for treatment of accidental Injury are limited to the

following:

Emergency examination.

Necessary diagnostic X-rays.

Endodontic (root canal)

treatment.

Temporary splinting of

teeth.

Prefabricated post and core.

Simple minimal restorative procedures

(fillings).

Extractions.

Post-traumatic crowns if such are the only clinically acceptable treatment.

Replacement of lost teeth due to the Injury by implant, dentures or

bridges.

5. Diabetes Services

Diabetes Self-Management and Training/Diabetic Eye Examinations/Foot Care

Outpatient self-management training for the treatment of diabetes, education and medical nutrition

therapy

services. Diabetes outpatient self-management training, education and medical nutrition therapy services must

be

ordered by a Physician and provided by appropriately licensed or registered healthcare

professionals.

Benefits under this section also include medical eye examinations (dilated retinal examinations) and

preventive

foot care for Covered Persons with

diabetes.

Diabetic Self-Management Items

Insulin pumps and supplies for the management and treatment of diabetes, based upon the medical needs of the

Covered Person. Benefits for blood glucose monitors, insulin syringes with needles, blood glucose and urine test

strips, ketone test strips and tablets and lancets and lancet devices are described under the Outpatient

Prescription Drug Rider.

6. Durable Medical Equipment

Durable Medical Equipment that meets each of the following criteria:

Ordered or provided by a Physician for outpatient use primarily in a home

setting.

Used

for medical

purposes.

Not consumable or disposable except as needed for the effective use of covered Durable Medical

Equipment.

Not of use to a person in the absence of a disease or disability.

COC.I.11.WI

11

Benefits under this section include Durable Medical Equipment provided to you by a Physician.

If more than one piece of Durable Medical Equipment can meet your functional needs, Benefits are available only

for the equipment that meets the minimum specifications for your needs.

Examples of Durable Medical Equipment include:

Equipment to assist mobility, such as a standard wheelchair.

A

standard Hospital-type

bed.

Oxygen and the rental of equipment to administer oxygen (including tubing, connectors and masks).

Delivery pumps for tube feedings (including tubing and connectors).

Negative pressure wound therapy pumps (wound

vacuums).

Braces, including necessary adjustments to shoes to accommodate braces. Braces that stabilize an injured

body part and braces to treat curvature of the spine are considered Durable Medical Equipment and are a

Covered Health Service. Braces that straighten or change the shape of a body part are orthotic devices, and

are excluded from coverage. Dental braces are also excluded from coverage.

Mechanical equipment necessary for the treatment of chronic or acute respiratory failure (except that

air-conditioners, humidifiers, dehumidifiers, air purifiers and filters and personal comfort items are excluded

from coverage).

Burn

garments.

Insulin pumps and all related necessary supplies as described under Diabetes Services.

External cochlear devices and systems. Benefits for cochlear implantation are provided under the applicable

medical/surgical Benefit categories in this

Certificate,

as required by Wisconsin insurance law.

Benefits under this section also include speech aid devices and tracheo-esophageal voice devices required for

treatment of severe speech impediment or lack of speech directly attributed to Sickness or Injury. Benefits for the

purchase of speech aid devices and tracheo-esophageal voice devices are available only after completing a

required three-month rental period. Benefits are limited as stated in the Schedule of Benefits.

Benefits under this section do not include any device, appliance, pump, machine, stimulator, or monitor that is

fully implanted into the body.

We will decide if the equipment should be purchased or rented.

Benefits are available for repairs and replacement, except that:

Benefits for repair and replacement do not apply to damage due to misuse, malicious breakage or

gross

neglect.

Benefits are not available to replace lost or stolen

items.

7. Emergency Health Services - Outpatient

Services that are required to stabilize or initiate treatment in an Emergency. Emergency Health Services must

be

received on an outpatient basis at a Hospital or Alternate

Facility.

Benefits under this section include the facility charge, supplies and all professional services required to

stabilize

your condition and/or initiate treatment. This includes placement in an observation bed for the purpose

of

monitoring your condition (rather than being admitted to a Hospital for an Inpatient

Stay).

Benefits under this section are not available for services to treat a condition that does not meet the definition of

an

Emergency.

8. Hearing Aids

Hearing aids required for the correction of a hearing impairment (a reduction in the ability to perceive

sound

which may range from slight to complete deafness). Hearing aids are electronic amplifying devices designed to

bring sound more effectively into the ear. A hearing aid consists of a microphone, amplifier and receiver.

Benefits are available for a hearing aid that is purchased as a result of a written recommendation by a Physician.

Benefits are provided for the hearing aid and for charges for associated fitting and testing.

COC.I.11.WI

12

Benefits under this section do not include bone anchored hearing aids. Bone anchored hearing aids are a

Covered Health Service for which Benefits are available under the applicable medical/surgical Covered Health

Services categories in this

Certificate,

only for Covered Persons who have either of the following:

Craniofacial anomalies whose abnormal or absent ear canals preclude the use of a wearable hearing aid.

Hearing loss of sufficient severity that it would not be adequately remedied by a wearable hearing

aid.

Benefits under this section include hearing aids for Enrolled Dependent children under 18 years of age

as

required by Wisconsin insurance

law.

9. Home Health Care

Services received from a Home Health Agency that are both of the

following:

Ordered by a Physician.

Provided in your home by a registered nurse, or provided by either a home health aide or licensed practical

nurse and supervised by a registered nurse.

Benefits are available only when the Home Health Agency services are provided on a part-time, Intermittent Care

schedule and when skilled care is required.

Skilled care is skilled nursing, skilled teaching and skilled rehabilitation services when all of the following are true:

It must be delivered or supervised by licensed technical or professional medical personnel in order to

obtain

the

specified medical outcome, and provide for the safety of the

patient.

It is ordered by a

Physician.

It is not delivered for the purpose of assisting with activities of daily living, including dressing, feeding,

bathing or transferring from a bed to a chair.

It requires clinical training in order to be delivered safely and

effectively.

It

is not Custodial

Care.

We will determine if Benefits are available by reviewing both the skilled nature of the service and the need

for

Physician-directed medical management. A service will not be determined to be "skilled" simply because there

is

not an available

caregiver.

10. Hospice Care

Hospice care that is recommended by a Physician. Hospice care is an integrated program that provides

comfort

and support services for the terminally ill. Hospice care includes physical, psychological, social, spiritual

and

respite care for the terminally ill person and short-term grief counseling for immediate family members while

the

Covered Person is receiving hospice care. Benefits are available when hospice care is received from a

licensed

hospice

agency.

Please contact us for more information regarding our guidelines for hospice care. You can contact us at

the

telephone number on your ID

card.

11. Hospital - Inpatient Stay

Services and supplies provided during an Inpatient Stay in a Hospital. Benefits are available

for:

Supplies and non-Physician services received during the Inpatient

Stay.

Room and board in a Semi-private Room (a room with two or more beds).

Physician services for radiologists, anesthesiologists, pathologists and Emergency room

Physicians.

(Benefits for other Physician services are described under Physician Fees for Surgical and Medical Services.)

12. Lab, X-Ray and Diagnostics - Outpatient

Services for Sickness and Injury-related diagnostic purposes, received on an outpatient basis at a Hospital or

Alternate Facility include:

Lab and radiology/X-ray, including blood lead tests for children under the age of

six.

COC.I.11.WI

13

Mammography.

Benefits under this section include:

The facility charge and the charge for supplies and

equipment.

Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician services

are described under Physician Fees for Surgical and Medical Services.)

When these services are performed in a Physician’s office, Benefits are described under Physician’s Office

Services - Sickness and Injury.

Lab, X-ray and diagnostic services for preventive care are described under Preventive Care Services.

CT scans, PET scans, MRI, MRA, nuclear medicine and major diagnostic services are described under Lab,

X-Ray and Major

Diagnostics

- CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient.

13. Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine -

Outpatient

Services for CT scans, PET scans, MRI, MRA, nuclear medicine and major diagnostic services received on an

outpatient basis at a Hospital or Alternate Facility or in a Physician’s office.

Benefits under this section include:

The facility charge and the charge for supplies and equipment.

Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician

services

are

described under Physician Fees for Surgical and Medical Services.)

14. Mental Health Services

Mental Health Services include those received on an inpatient basis in a Hospital or an Alternate Facility,

and

those received on an outpatient basis in a provider’s office or at an Alternate

Facility.

Benefits include the following services provided on either an inpatient or outpatient

basis:

Diagnostic evaluations and

assessment.

Treatment planning.

Referral

services.

Medication

management.

Individual, family, therapeutic group and provider-based case management services.

Crisis

intervention.

Benefits include the following services provided on an inpatient

basis:

Partial

Hospitalization/Day Treatment.

Services at a Residential Treatment Facility.

Benefits include the following services provided on an outpatient

basis:

Intensive Outpatient Treatment.

The Mental Health/Substance Use Disorder Designee determines coverage for all levels of care. If an Inpatient

Stay is required, it is covered on a Semi-private Room basis.

We encourage you to contact the Mental Health/Substance Use Disorder Designee for referrals to providers and

coordination of care.

Special Mental Health Programs and Services

Special programs and services that are contracted under the Mental Health/Substance Use Disorder Designee

may become available to you as a part of your Mental Health Services Benefit. The Mental Health Services

Benefits and financial requirements assigned to these programs or services are based on the designation of the

program or service to inpatient, Partial Hospitalization/Day Treatment, Intensive Outpatient Treatment, outpatient

or a Transitional Care category of Benefit use. Special programs or services provide access to services that are

beneficial for the treatment of your Mental Illness which may not otherwise be covered under the Policy. You must

COC.I.11.WI

14

be referred to such programs through the Mental Health/Substance Use Disorder Designee, who is responsible

for coordinating your care or through other pathways as described in the program introductions . Any decision to

participate in such a program or service is at the discretion of the Covered Person and is not mandatory.

Coverage will be provided for the Mental Health clinical assessments of Dependent Full-time Students

attending school in the State of Wisconsin but outside of the Service Area. The clinical assessment must be

conducted by a provider designated by the Mental Health/Substance Use Designee and who is located in the

State of Wisconsin and in reasonably close proximity to the Full-time Student’s school. If outpatient Mental

Health/Substance Use Disorder Services are recommended, coverage will be provided for a maximum of 5

visits at an outpatient treatment facility or other provider designated by the Mental Health/Substance Use

Disorder Designee, that is located in the State of Wisconsin and in reasonably close proximity to the Full-time

Student’s school. Coverage for the outpatient services will not be provided, if the

recommende

d treatment

would prohibit the Dependent from attending school on a regular basis or if the Dependent is no longer a

Full-time Student.

Mental Health Services received on a transitional care basis including:

Services for children and adults in day treatment

programs.

Services for persons with chronic Mental Illness provided through a community support program.

Coordinated Emergency Mental Health Services for Covered Persons who are experiencing a mental health

crisis or who are in a situation likely to turn into a mental health crisis if support is not provided. Benefits for

these services are to be provided for the time period the Covered Person is experiencing the crisis until

he/she is stabilized or referred to other provider for stabilization.

The Wisconsin Department of Health and Social Services must certify day treatment programs,

community

support programs and residential treatment programs and crisis intervention

programs.

15. Ostomy Supplies

Benefits for ostomy supplies are limited to the

following:

Pouches, face plates and

belts.

Irrigation

sleeves,

bags and ostomy irrigation catheters.

Skin

barriers.

Benefits are not available for deodorants, filters, lubricants, tape, appliance cleaners, adhesive, adhesive

remover,

or other items not listed

above.

16. Pharmaceutical Products - Outpatient

Pharmaceutical Products that are administered on an outpatient basis in a Hospital, Alternate Facility,

Physician’s

office, or in a Covered Person’s

home.

Benefits under this section are provided only for Pharmaceutical Products which, due to their characteristics

(as

determined by us), must typically be administered or directly supervised by a qualified provider

or

licensed/certified health professional. Benefits under this section do not include medications that are typically

available by prescription order or refill at a pharmacy.

We may have certain programs in which you may receive an enhanced or reduced Benefit based on your actions

such as adherence/compliance to medication or treatment regimens and/or participation in health management

programs. You may access information on these programs through the Internet at www.myuhc.com or by calling

Customer Care at the telephone number on your ID card.

17. Physician Fees for Surgical and Medical Services

Physician fees for surgical procedures and other medical care received on an outpatient or inpatient basis in a

Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility or Alternate Facility, or for Physician house calls.

COC.I.11.WI

15

18. Physician’s Office Services - Sickness and Injury

Services provided in a Physician’s office for the diagnosis and treatment of a Sickness or Injury. Benefits are

provided under this section regardless of whether the Physician’s office is free-standing, located in a clinic or

located in a Hospital.

Covered Health Services include medical education services that are provided in a Physician’s office by

appropriately licensed or registered healthcare professionals when both of the following are true:

Education is required for a disease in which patient self-management is an important component of

treatment.

There exists a knowledge deficit regarding the disease which requires the intervention of a trained

health

professional.

Covered Health Services include genetic counseling. Benefits are available for Genetic Testing which is

ordered

by the Physician and authorized in advance by

us.

Benefits under this section include allergy

injections.

Covered Health Services for preventive care provided in a Physician’s office are described under Preventive Care

Services.

Benefits under this section include lab, radiology/X-ray or other diagnostic services performed in the

Physician’s

office. Benefits under this section do not include CT scans, PET scans, MRI, MRA, nuclear medicine and

major

diagnostic

services.

19. Pregnancy - Maternity Services

Benefits for Pregnancy include all maternity-related medical services for prenatal care, postnatal care,

delivery

and any related

complications.

Both before and during a Pregnancy, Benefits include the services of a genetic counselor when provided

or

referred by a Physician. These Benefits are available to all Covered Persons in the immediate family.

Covered

Health Services include related tests and

treatment.

We also have special prenatal programs to help during Pregnancy. They are completely voluntary and there is

no

extra cost for participating in the program. To sign up, you should notify us during the first trimester, but no

later

than one month prior to the anticipated childbirth. It is important that you notify us regarding your

Pregnancy.

Your notification will open the opportunity to become enrolled in prenatal programs designed to achieve the

best

outcomes for you and your

baby.

We will pay Benefits for an Inpatient Stay of at

least:

48 hours for the mother and newborn child following a normal vaginal

delivery.

96 hours for the mother and newborn child following a cesarean section delivery.

If the mother agrees, the attending provider may discharge the mother and/or the newborn child earlier than

these minimum time frames.

20. Preventive Care Services

Preventive care services provided on an outpatient basis at a Physician’s office, an Alternate Facility or a

Hospital

encompass medical services that have been demonstrated by clinical evidence to be safe and effective in

either

the early detection of disease or in the prevention of disease, have been proven to have a beneficial effect

on

health outcomes and include the following as required under applicable

law:

Evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of

the United States Preventive Services Task Force.

Immunizations that have in effect a recommendation from the Advisory Committee on

Immunization

Practices

of the Centers for Disease Control and Prevention.

With respect to infants, children and adolescents, evidence-informed preventive care and

screenings

provided for in the comprehensive guidelines supported by the Health Resources and Services

Administration.

COC.I.11.WI

16

With respect to women, such additional preventive care and screenings as provided for in comprehensive

guidelines supported by the Health Resources and Services Administration.

21. Prosthetic Devices

External prosthetic devices that replace a limb or a body part, limited to:

Artificial arms, legs, feet and

hands.

Artificial face, eyes, ears and nose.

Breast prosthesis as required by the Women’s Health and Cancer Rights Act of 1998. Benefits include

mastectomy bras and lymphedema stockings for the arm.

Benefits under this section are provided only for external prosthetic devices and do not include any device that is

fully implanted into the body.

If more than one prosthetic device can meet your functional needs, Benefits are available only for the prosthetic

device that meets the minimum specifications for your needs. If you purchase a prosthetic device that exceeds

these minimum specifications, we will pay only the amount that we would have paid for the prosthetic that meets

the minimum specifications, and you will be responsible for paying any difference in cost.

The prosthetic device must be ordered or provided by, or under the direction of a Physician.

Benefits are available for repairs and replacement, except that:

There are no Benefits for repairs due to misuse, malicious damage or gross

neglect.

There are no Benefits for replacement due to misuse, malicious damage, gross neglect or for lost or

stolen

prosthetic

devices.

22. Reconstructive Procedures

Reconstructive procedures when the primary purpose of the procedure is either to treat a medical condition or

to

improve or restore physiologic function. Reconstructive procedures include surgery or other procedures

which

are associated with an Injury, Sickness or Congenital Anomaly. The primary result of the procedure is not

a

changed or improved physical

appearance.

Cosmetic Procedures are excluded from coverage. Procedures that correct an anatomical Congenital

Anomaly

without improving or restoring physiologic function are considered Cosmetic Procedures. The fact that a

Covered

Person may suffer psychological consequences or socially avoidant behavior as a result of an Injury, Sickness

or

Congenital Anomaly does not classify surgery (or other procedures done to relieve such consequences

or

behavior) as a reconstructive

procedure.

Please note that Benefits for reconstructive procedures include breast reconstruction following a mastectomy,

and

reconstruction of the non-affected breast to achieve symmetry. Other services required by the Women’s Health

and Cancer Rights Act of 1998,

including breast prostheses and treatment of complications, are provided in

the

same manner and at the same level as those for any other Covered Health Service. You can contact us at

the

telephone number on your ID card for more information about Benefits for

mastectomy-related services.

23. Rehabilitation Services - Outpatient Therapy and Manipulative Treatment

Short-term outpatient rehabilitation services, limited

to:

Physical

therapy.

Occupational therapy. This does not include services as described under Autism Spectrum Disorder Services

in this section.

Manipulative

Treatment.

Speech therapy. This does not include services as described under Autism Spectrum Disorder Services

in

this

section.

Pulmonary rehabilitation therapy.

Cardiac rehabilitation therapy.

Post-cochlear implant aural

therapy.

COC.I.11.WI

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Cognitive rehabilitation therapy.

Rehabilitation services must be performed by a Physician or by a licensed therapy provider. Benefits under this

section include rehabilitation services provided in a Physician’s office or on an outpatient basis at a Hospital or

Alternate Facility.

Benefits can be denied or shortened for Covered Persons who are not progressing in goal-directed rehabilitation

services or if rehabilitation goals have previously been met. Benefits can be denied or shortened for Covered

Persons who are not progressing in goal-directed Manipulative Treatment or if treatment goals have previously

been met. Benefits under this section are not available for maintenance/preventive Manipulative Treatment.

Please note that we will pay Benefits for speech therapy for the treatment of disorders of speech, language, voice,

communication and auditory processing only when the disorder results from Injury, stroke, cancer, or Congenital

Anomaly. For speech therapy with relation to Autism Spectrum Disorders, please refer to the services described

under Autism Spectrum Disorder Services in this section. We will pay Benefits for cognitive rehabilitation therapy

only when Medically Necessary following a post-traumatic brain Injury or cerebral vascular accident.

24. Scopic Procedures - Outpatient Diagnostic and Therapeutic

Diagnostic and therapeutic scopic procedures and related services received on an outpatient basis at a Hospital

or Alternate Facility or in a Physician’s office.

Diagnostic scopic procedures are those for visualization, biopsy and polyp removal. Examples of diagnostic

scopic procedures include colonoscopy, sigmoidoscopy and endoscopy.

Please note that Benefits under this section do not include surgical scopic procedures, which are for the purpose

of performing surgery. Benefits for surgical scopic procedures are described under Surgery - Outpatient.

Examples of surgical scopic procedures include arthroscopy, laparoscopy, bronchoscopy and

hysterosco

py.

Benefits under this section include:

The facility charge and the charge for supplies and

equipment.

Physician services for radiologists, anesthesiologists and pathologists. (Benefits for all other

Physician

services are described under Physician Fees for Surgical and Medical Services.)

When these services are performed for preventive screening purposes, Benefits are described under Preventive

Care Services.

25. Skilled Nursing Facility/Inpatient Rehabilitation Facility Services

Services and supplies provided during an Inpatient Stay in a Skilled Nursing Facility or Inpatient

Rehabilitation

Facility. Benefits are available

for:

Supplies and non-Physician services received during the Inpatient Stay.

Room and board in a Semi-private Room (a room with two or more

beds).

Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician

services

are

described under Physician Fees for Surgical and Medical Services.)

Please note that Benefits are available only if both of the following are

true:

If the initial confinement in a Skilled Nursing Facility or Inpatient Rehabilitation Facility was or will be a

cost

effective alternative to an Inpatient Stay in a

Hospital.

You will receive skilled care services that are not primarily Custodial Care.

Skilled care is skilled nursing, skilled teaching and skilled rehabilitation services when all of the following are true:

It must be delivered or supervised by licensed technical or professional medical personnel in order to

obtain

the

specified medical outcome, and provide for the safety of the

patient.

It is ordered by a

Physician.

It is not delivered for the purpose of assisting with activities of daily living, including dressing, feeding,

bathing or transferring from a bed to a chair.

It requires clinical training in order to be delivered safely and

effectively.

COC.I.11.WI

18

We will determine if Benefits are available by reviewing both the skilled nature of the service and the need for

Physician-directed medical management. A service will not be determined to be "skilled" simply because there is

not an available caregiver.

Benefits can be denied or shortened for Covered Persons who are not progressing in goal-directed rehabilitation

services or if discharge rehabilitation goals have previously been met.

26. Substance Use Disorder Services

Substance Use Disorder Services include those received on an inpatient basis in a Hospital or an Alternate

Facility, and those received on an outpatient basis in a provider’s office or at an Alternate Facility.

Benefits include the following services provided on either an inpatient or outpatient basis:

Diagnostic evaluations and assessment.

Treatment

planning.

Referral services.

Medication management.

Individual, family, therapeutic group and provider-based case management

services.

Crisis intervention.

Benefits include the following services provided on an inpatient

basis:

Partial Hospitalization/Day Treatment.

Services at a Residential Treatment

Facility.

Benefits include the following services provided on an outpatient

basis:

Intensive Outpatient

Treatment.

The Mental Health/Substance Use Disorder Designee determines coverage for all levels of care. If an

Inpatient

Stay is required, it is covered on a Semi-private Room

basis.

We encourage you to contact the Mental Health/Substance Use Disorder Designee for referrals to providers

and

coordination of

care.

Special Substance Use Disorder Programs and Services

Special programs and services that are contracted under the Mental Health/Substance Use Disorder

Designee

may become available to you as a part of your Substance Use Disorder Services Benefit. The Substance

Use

Disorder Services Benefits and financial requirements assigned to these programs or services are based on

the

designation of the program or service to inpatient, Partial

Hospitalization/Day

Treatment, Intensive

Outpatient

Treatment, outpatient or a Transitional Care category of Benefit use. Special programs or services provide

access

to services that are beneficial for the treatment of your substance use disorder which may not otherwise

be

covered under the Policy. You must be referred to such programs through the Mental Health/Substance

Use

Disorder Designee, who is responsible for coordinating your care or through other pathways as described in

the

program introductions. Any decision to participate in such a program or service is at the discretion of

the

Covered Person and is not

mandatory.

Coverage will be provided for the Mental Health clinical assessments of Dependent Full-time Students

attending

school in the State of Wisconsin but outside of the Service Area. The clinical assessment must be conducted by

a

provider designated by the Mental Health/Substance Use Designee and who is located in the State of

Wisconsin

and in reasonably close proximity to the Full-time Student’s school. If outpatient Mental Health/Substance

Use

Disorder Services are recommended, coverage will be provided for a maximum of 5 visits at an

outpatient

treatment facility or other provider designated by the Mental Health/Substance Use Disorder Designee, that

is

located in the State of Wisconsin and in reasonably close proximity to the Full-time Student’s school. Coverage

for

the outpatient services will not be provided, if the recommended treatment would prohibit the Dependent

from

attending school on a regular basis or if the Dependent is no longer a Full-time Student.

Mental Health Services received on a transitional care basis including:

Residential treatment programs for alcoholism and other drug dependent Covered

Persons.

Substance Use Disorder Treatment for alcohol and drug dependent Covered

Persons.

COC.I.11.WI

19

Intensive outpatient programs for the treatment of psychoactive substance abuse disorders.

The Wisconsin Department of Health and Social Services must certify day treatment programs,

community

support programs and residential treatment programs and crisis intervention

programs.

27. Surgery - Outpatient

Surgery and related services received on an outpatient basis at a Hospital or Alternate Facility or in a

Physician’s

office.

Benefits under this section include certain scopic procedures. Examples of surgical scopic procedures

include

arthroscopy, laparoscopy, bronchoscopy and

hysteroscopy.

Examples of surgical procedures performed in a Physician’s office are mole removal and ear wax

removal.

Benefits under this section

include:

The facility charge and the charge for supplies and equipment.

Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician services

are described under Physician Fees for Surgical and Medical Services.)

28. Temporomandibular Joint Disorder Services

Diagnostic procedures and surgical or non-surgical treatment (including prescribed intraoral splint therapy

devices) for the correction of temporomandibular joint disorders (TMJ) and associated muscles if all of the

following apply:

The condition is caused by congenital, developmental or acquired deformity, disease or

Injury.

There is clearly demonstrated radiographic evidence of significant joint

abnormality.

The procedure or device is reasonable and appropriate for the diagnosis or treatment of the condition.

The purpose of the procedure or device is to control or eliminate infection, pain, disease or

dysfunction.

Benefits are not available for cosmetic or elective orthodontic care, periodontic care or general dental

care.

Benefits for surgical services include arthrocentesis, arthroscopy, arthroplasty, arthrotomy and open or

closed

reduction of

dislocations.

Non-surgical treatment including clinical examinations, oral appliances (orthotic splints), arthrocent esis

and

trigger-point

injections.

29. Therapeutic Treatments - Outpatient

Therapeutic treatments received on an outpatient basis at a Hospital or Alternate Facility or in a Physician’s

office,

including dialysis (both hemodialysis and peritoneal dialysis), intravenous chemotherapy or other

intravenous

infusion therapy and radiation

oncology.

Covered Health Services include medical education services that are provided on an outpatient basis at

a

Hospital or Alternate Facility by appropriately licensed or registered healthcare professionals when both of

the

following are

true:

Education is required for a disease in which patient self-management is an important component

of

treatment.

There exists a knowledge deficit regarding the disease which requires the intervention of a trained health

professional.

Benefits under this section include:

The facility charge and the charge for related supplies and

equipment.

Physician services for anesthesiologists, pathologists and radiologists. Benefits for other Physician

services

are

described under Physician Fees for Surgical and Medical Services.

COC.I.11.WI

20

30. Transplantation Services

Organ and tissue transplants when ordered by a Physician. Benefits are available for transplants when the

transplant meets the definition of a Covered Health Service, and is not an Experimental or Investigational or

Unproven Service.

Examples of transplants for which Benefits are available include bone marrow, heart, heart/lung, lung, kidney,

kidney/pancreas, liver, liver/small bowel, pancreas, small bowel and cornea.

Donor costs that are directly related to organ removal are Covered Health Services for which Benefits are payable

through the organ recipient’s coverage under the Policy.

We have specific guidelines regarding Benefits for transplant services. Contact us at the telephone number on

your ID card for information about these guidelines.

31. Urgent Care Center Services

Covered Health Services received at an Urgent Care Center. When services to treat urgent health care needs are

provided in a Physician’s office, Benefits are available as described under Physician’s Office Services - Sickness

and Injury.

32. Vision Examinations

Routine vision examinations, including refraction to detect vision impairment, received from a health

care

provider in the provider’s

office.

Please note that Benefits are not available for charges connected to the purchase or fitting of eyeglasses

or

contact

lenses.

Benefits for eye examinations required for the diagnosis and treatment of a Sickness or Injury are provided

under

Physician’s Office Services - Sickness and Injury.

Additional Benefits Required By Wisconsin Law

33. Autism Spectrum Disorder Services

The following definitions apply for purposes of Autism Spectrum

Disorders:

"Intensive level services" means evidence-based behavioral therapies that is designed to help an individual

with Autism Spectrum Disorder overcome the cognitive, social and behavioral deficits associated with that

disorder. Intensive level services may include evidence-based speech therapy and occupational therapy

provided by a qualified therapist when such therapy is based on, or related to, an individual’s therapeutic

goals and skills, and is concomitant with evidence-based behavioral therapy.

"Non intensive level services" means evidence-based therapy that occurs after the completion of

treatment

for

Intensive level services and that is designed to sustain and maximize gains made during treatment

with

Intensive level services or, for an individual who has not and will not receive intensive level services,

evidence-based therapy that will improve the individual’s condition.

Intensive Level

Services

Note: Benefits for intensive-level services begin after the Enrolled Dependent child turns two years of age

but prior to turning nine years of age.

Benefits are provided for evidence-based behavioral intensive level therapy for an insured with a verified

diagnosis of Autism Spectrum Disorder, the majority of which shall be provided to the Enrolled Dependent child

when the parent or legal guardian is present and engaged. The prescribed therapy must be consistent with all of

the following requirements:

Based upon a treatment plan developed by an individual who at least meets the requirements of a qualified

intensive level provider or a qualified intensive level professional that includes at least 20 hours per week over

a six-month period of time of evidence-based behavioral intensive therapy, treatment and services with

specific cognitive, social, communicative, self-care, or behavioral goals that are clearly defined, directly

COC.I.11.WI

21

observed and continually measured and that address the characteristics of Autism Spectrum Disorders.

Treatment plans shall require that the Enrolled Dependent child be present and engaged in the intervention.

Implemented by qualified providers, qualified professional, qualified therapists or qualified paraprofessionals.

Provided in an environment most conducive to achieving the goals of the Enrolled Dependent

child’s

treatment

plan.

Included training and consultation, participation in team meeting and active involvement of the Enrolled

Dependent child’s family and treatment team for implementation of the therapeutic goals developed by the

team.

The Enrolled Dependent child is directly observed by the qualified intensive level provider or qualified

intensive level professional at least once every two months.

Beginning after the Enrolled Dependent child is two years of age and before the Enrolled Dependent child

is

nine

years of

age.

Intensive level services will be covered for up to four cumulative years. We may credit against any previous

intensive level services the Enrolled Dependent child received against the required four years of intensive

level services regardless of payer. We may also require documentation including medical records and

treatment plans to verify any evidence-based behavioral therapy the insured received for Autism Spectrum

Disorders that was provided to the Enrolled Dependent child prior to attaining nine years of age.

Evidence-based behavioral therapy that was provided to the Enrolled Dependent child for an average of 20

or more hours per week over a continuous six-month period to be intensive-level services.

Travel time for qualified providers, supervising providers, professionals, therapists, paraprofessionals or

behavioral analysts is not included when calculating the number of hours of care provided per week. We are

not required to reimburse for travel time.

We require that progress be assessed and documented throughout the course of treatment. We may

request

and

review the Enrolled Dependent child’s treatment plan and the summary of progress on a periodic

basis.

We will cover services from a qualified therapist when services are rendered concomitant with intensive

level

evidence-based behavioral therapy and all of the following

apply:

The qualified therapist provides evidence-based therapy to an Enrolled Dependent child who has

a

primary diagnosis of an Autism Spectrum

Disorder.

The Enrolled Dependent child is actively receiving behavioral services from a qualified intensive

level

provider or qualified intensive level

professional.

The qualified therapist develops and implements a treatment plan consistent with their license and

this

section.

Non-Intensive Level

Services

Non intensive Level Services will be covered for an Enrolled Dependent child with a verified diagnosis of

Autism

Spectrum Disorder for non intensive level services that are evidence-based and are provided to an

Enrolled

Dependent child by a qualified provider, qualified professional, qualified therapist or qualified paraprofessional

in

either of the following

conditions:

After the completion of intensive level services and designed to sustain and maximize gains made

during

intensive level services

treatment.

To an Enrolled Dependent child who has not and will not receive intensive level services but for whom

non-intensive level services will improve the Enrolled Dependent child’s condition.

Benefits will be provided for evidence-based therapy that is consistent with all of the following requirements:

Based upon a treatment plan developed by an individual who minimally meets the requirements as

a

qualified provider, qualified professional or qualified therapist that includes evidence-based specific

therapy

goals that are clearly defined, directly observed and continually measured and that address

the

characteristics of Autism Spectrum Disorders. Treatment plans shall require that the Enrolled

Dependent

child be present and engaged in the intervention.

Implemented by qualified providers, qualified professionals, qualified therapist or qualified

paraprofessionals.

Provided in an environment most conducive to achieving the goal of the Enrolled Dependent child’s

treatment plan.

COC.I.11.WI

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Included training and consultation, participation in team meetings and active involvement of the Enrolled

Dependent child’s family in order to implement the therapeutic goals developed by the team.

Non intensive level services may include direct or consultative services when provided by qualified

providers,

qualified supervising providers, qualified professionals, qualified paraprofessionals, or qualified

therapists.

We require that progress be assessed and documented throughout the course of treatment. We may request

and review the Enrolled Dependent child’s treatment plan and the summary of progress on a periodic basis.

Travel time for qualified providers, qualified supervising providers, qualified professional, qualified therapists,

qualified paraprofessionals or qualified behavioral analysts is not included when calculating the number of

hours of care provided per week. We are not required to reimburse for travel time.

Intensive level and Non intensive level services include but are not limited to speech, occupational and behavioral

therapies.

The following services are not covered under the Autism Spectrum Disorders:

Acupuncture.

Animal-based therapy including hippotherapy.

Auditory integration training.

Chelation

therapy.

Child care fees.

Cranial sacral therapy.

Custodial or respite

care.

Hyperbaric oxygen

therapy.

Special diets or supplements.

Pharmaceuticals and durable medical

equipment.

34. Dental/Anesthesia Services - Hospital or Ambulatory Surgery Services

Hospital and ambulatory surgery center charges provided in conjunction with dental care, including

anesthetics

provided, if any of the following

applies:

The Covered Person is a child under the age of

five.

The

Covered Person has a chronic disability.

The Covered Person has a medical condition requiring hospitalization or general anesthesia for dental

care.

35. Kidney Disease Treatment

Inpatient and outpatient kidney disease treatment including dialysis, transplantation and donor-rela ted

services.

COC.I.11.WI

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Section 2: Exclusions and

Limitations

How We Use Headings in this Section

To help you find specific exclusions more easily, we use headings (for example A. Alternative Treatments below).

The headings group services, treatments, items, or supplies that fall into a similar category. Actual exclusions

appear underneath headings. A heading does not create, define, modify, limit or expand an exclusion. All

exclusions in this section apply to you.

We do not Pay Benefits for Exclusions

We will not pay Benefits for any of the services, treatments, items or supplies described in this section, even if

either of the following is true:

It is recommended or prescribed by a Physician.

It is the only available treatment for your

condition.

The services, treatments, items or supplies listed in this section are not Covered Health Services, except as

may

be specifically provided for in Section 1: Covered Health Services or through a Rider to the

Policy.

Benefit Limitations

When Benefits are limited within any of the Covered Health Service categories described in Section 1: Covered

Health Services,

those limits are stated in the corresponding Covered Health Service category in the Schedule of

Benefits.

Limits may also apply to some Covered Health Services that fall under more than one Covered

Health

Service category. When this occurs, those limits are also stated in the Schedule of Benefits under the

heading

Benefit Limits. Please review all limits carefully, as we will not pay Benefits for any of the services,

treatments,

items or supplies that exceed these Benefit

limits.

Please note that in listing services or examples, when we say "this includes," it is not our intent to limit the

description to that specific list. When we do intend to limit a list of services or examples, we state

specifically that the list "is limited to."

A. Alternative Treatments

1. Acupressure and

acupuncture.

2.

Aromatherapy.

3.

Hypnotism.

4. Massage

therapy.

5. Rolfing.

6. Art therapy, music therapy, dance therapy, horseback therapy and other forms of alternative treatment as

defined by the

National

Center for

Complementary

and

Alternative

Medicine (NCCAM) of the National

Institutes of Health. This exclusion does not apply to Manipulative Treatment and

non-manipula

tive

osteopathic care for which Benefits are provided as described in Section 1: Covered Health Services.

B. Autism Spectrum Disorder Services

Exclusions listed directly below apply to services described under Autism Spectrum Disorder Services in Section

1: Covered Health Services.

1. Services as treatments of sexual dysfunction and feeding disorders as listed in the current edition of the

Diagnostic

and

Statistical

Manual of the American Psychiatric Association.

COC.I.11.WI

24

2. Any treatments or other specialized services designed for Autism Spectrum Disorder that are not backed

by credible research demonstrating that the services or supplies have a measurable and beneficial health

outcome and therefore considered Experimental or Investigational or Unproven Services.

3. Mental retardation as the primary diagnosis defined in the current edition of the

Diagnostic

and Statistical

Manual of the American Psychiatric Association.

4. Tuition for or services that are school-based for children and adolescents under the

Individuals

with

Disabilities

Education Act.

5. Learning, motor skills and primary communication disorders as defined in the current edition of the

Diagnostic

and

Statistical

Manual of the American Psychiatric Association and which are not a part of Autism

Spectrum Disorder.

6. Treatments for the primary diagnoses of learning disabilities, conduct and impulse control disorders,

personality disorders and paraphilias. This exclusion does not apply for Autism Spectrum Disorder

Services provided as the result of an Emergency detention, commitment or court order.

7. Services or supplies for the diagnosis or treatment of Mental Illness that, in the reasonable judgment of the

Mental Health/Substance Use Disorder Designee, are any of the following:

Not consistent with generally accepted standards of medical practice for the treatment of such

conditions.

Not consistent with services backed by credible research soundly demonstrating that the services

or

supplies will have a measurable and beneficial health outcome, and therefore considered

experimental.

Not consistent with the Mental Health/Substance Use Disorder Designee’s level of care guidelines

or

best practices as modified from time to

time.

Not clinically appropriate for the patient’s Mental Illness or condition based on generally

accepted

standards of medical practice and

benchmarks.

C. Dental

1. Dental care (which includes dental X-rays, supplies and appliances and all associated expenses,

including

hospitalizations and

anesthesia).

This exclusion does not apply to accident-related dental services for which Benefits are provided

as

described under Dental Services - Accident Only and

Dental/Anesthesia

Services -

Hospital

or Ambulatory

Surgery Services

and

Temporomandibular

Joint Disorder Services in Section 1: Covered Health Services.

This exclusion does not apply to dental care (oral examination, X-rays, extractions and

non-surgical

elimination of oral infection) required for the direct treatment of a medical condition for which Benefits

are

available under the Policy, limited

to:

Transplant

preparation.

Prior to the initiation of

immunosuppressive drugs.

The direct treatment of acute traumatic Injury, cancer or cleft

palate.

Dental care that is required to treat the effects of a medical condition, but that is not necessary to

directly

treat the medical condition, is excluded. Examples include treatment of dental caries resulting from

dry

mouth after radiation treatment or as a result of

medication.

Endodontics, periodontal surgery and restorative treatment are

excluded.

2. Preventive care, diagnosis, treatment of or related to the teeth, jawbones or gums. Examples

include:

Extraction, restoration and replacement of

teeth.

Medical or surgical treatments of dental conditions.

Services to improve dental clinical outcomes.

COC.I.11.WI

25

This exclusion does not apply to accident-related dental services for which Benefits are provided as

described under Dental Services - Accident Only and

Dental/Anesthesia

Services -

Hospital

or Ambulatory

Surgery Services and

Temporomandibular

Joint Disorder Services in Section 1: Covered Health Services.

3. Dental implants, bone grafts and other implant-related procedures. This exclusion does not apply to

accident-related dental services for which Benefits are provided as described under Dental Services -

Accident Only and

Dental/Anesthesia

Services -

Hospital

or

Ambulatory

Surgery Services and

Temporomandibular Joint Disorder Services in Section 1: Covered Health Services.

4. Dental braces (orthodontics).

5. Treatment of congenitally missing, malpositioned or supernumerary teeth, even if part of a Congenital

Anomaly.

D. Devices, Appliances and Prosthetics

1. Devices used specifically as safety items or to affect performance in sports-related activities.

2. Orthotic appliances that straighten or re-shape a body part. Examples include foot orthotics and some

types of braces, including over-the-counter orthotic braces.

3. Cranial banding.

4. The following items are excluded, even if prescribed by a Physician:

Blood pressure

cuff/monitor.

Enuresis

alarm.

Non-wearable external

defibrillator.

Trusses.

Ultrasonic

nebulizers.

5. Devices and computers to assist in communication and speech except for speech aid devices

and

tracheo-esophageal

voice devices for which Benefits are provided as described under Durable Medical

Equipment

in Section 1: Covered Health Services.

6. Oral appliances for

snoring.

7. Repairs to prosthetic devices due to misuse, malicious damage or gross

neglect.

8. Replacement of prosthetic devices due to misuse, malicious damage or gross neglect or to replace lost

or

stolen

items.

E. Drugs

1. Prescription drug products for outpatient use that are filled by a prescription order or

refill.

2. Self-injectable medications. This exclusion does not apply to medications which, due to

their

characteristics

(as determined by us), must typically be administered or directly supervised by a

qualified

provider or licensed/certified health professional in an outpatient

setting.

3. Non-injectable medications given in a Physician’s office. This exclusion does not apply to

non-injectable

medications that are required in an Emergency and consumed in the Physician’s

office.

4. Over-the-counter drugs and

treatments.

5. Growth hormone

therapy.

COC.I.11.WI

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F. Experimental or Investigational or Unproven Services

Experimental or Investigational and Unproven Services and all services related to Experimental or

Investigational and Unproven Services are excluded. The fact that an Experimental or

Investigati

onal or

Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a

particular condition will not result in Benefits if the procedure is considered to be Experimental or

Investigational or Unproven in the treatment of that particular condition.

Determination on whether services are Experimental, Investigational and Unproven Services are made by our

Medical Director in consultation with a specialty review panel. When we receive a request for an Experimental,

Investigational, or Unproven Service, we will issue a Benefit decision within five working days. If we decide there

is no coverage for the Experimental, Investigational, or Unproven treatment, procedure, or device for a Covered

Person with a terminal condition or Sickness, we will include the following information in the non-coverage letter:

A statement that includes the specific medical and scientific reasons for denying coverage.

A notice of the Covered Person’s right to appeal.

A description of the appeal process.

This exclusion does not apply to Covered Health Services provided during a clinical trial for which Benefits

are provided as described under

Clinical

Trials in Section 1: Covered Health Services.

G. Foot Care

1. Routine foot care. Examples include the cutting or removal of corns and calluses. This exclusion does

not

apply to preventive foot care for Covered Persons with diabetes for which Benefits are provided

as

described under Diabetes Services in Section 1: Covered Health Services.

2. Nail trimming, cutting, or

debriding.

3. Hygienic and preventive maintenance foot care. Examples

include:

Cleaning and soaking the

feet.

Applying skin creams in order to maintain skin

tone.

This exclusion does not apply to preventive foot care for Covered Persons who are at risk of

neurological

or vascular disease arising from diseases such as

diabetes.

4. Treatment of flat

feet.

5. Treatment of subluxation of the

foot.

6.

Shoes.

7. Shoe

orthotics.

8. Shoe

inserts.

9. Arch

supports.

H. Medical Supplies

1. Prescribed or non-prescribed medical supplies and disposable supplies. Examples

include:

Compression

stockings.

Ace

bandages.

Gauze and

dressings.

Urinary

catheters.

This exclusion does not apply to:

Disposable supplies necessary for the effective use of Durable Medical Equipment for which Benefits are

provided as described under Durable Medical Equipment in Section 1: Covered Health Services.

COC.I.11.WI

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Diabetic supplies for which Benefits are provided as described under Diabetes Services in Section 1:

Covered Health Services.

Ostomy supplies for which Benefits are provided as described under Ostomy Supplies in Section 1:

Covered Health Services.

2. Tubings and masks except when used with Durable Medical Equipment as described under Durable

Medical Equipment in Section 1: Covered Health Services.

I. Mental Health

Exclusions listed directly below apply to services described under Mental Health Services in Section 1: Covered

Health Services.

1. Services performed in connection with conditions not classified in the current edition of the

Diagnostic

and

Statistical

Manual of the American Psychiatric Association.

2. Mental Health Services as treatments for V-code conditions as listed within the current edition of the

Diagnostic

and

Statistical

Manual of the American Psychiatric Association.

3. Mental Health Services as treatment for a primary diagnosis of insomnia and other sleep disorders, sexual

dysfunction disorders, feeding disorders, neurological disorders and other disorders with a known

physical basis.

4. Treatments for the primary diagnoses of learning disabilities, conduct and impulse control

disorders,

personality disorders and paraphilias. This exclusion does not apply for Mental Health Services

provided

as the result of an Emergency detention, commitment or court

order.

5.

Educational/behavioral

services that are focused on primarily building skills and capabilities

in

communication, social interaction and

learning.

6. Tuition for or services that are school-based for children and adolescents under the Individuals with

Disabilities Education Act.

7. Learning, motor skills and primary communication disorders as defined in the current edition of

the

Diagnostic

and

Statistical

Manual of the American Psychiatric Association.

8. Mental retardation and autism spectrum disorder as a primary diagnosis defined in the current edition

of

the

Diagnostic

and

Statistical

Manual of the American Psychiatric

Association.

Benefits for autism

spectrum

disorder as a primary diagnosis are described under Autism Spectrum Disorder Services in Section 1:

Covered Health Services.

9. Services or supplies for the diagnosis or treatment of Mental Illness that, in the reasonable judgment of

the

Mental Health/Substance Use Disorder Designee, are any of the

following:

Not consistent with generally accepted standards of medical practice for the treatment of

such

conditions.

Not consistent with services backed by credible research soundly demonstrating that the services

or

supplies will have a measurable and beneficial health outcome, and therefore considered

experimental.

Not consistent with the Mental Health/Substance Use Disorder Designee’s level of care guidelines

or

best practices as modified from time to

time.

Not clinically appropriate for the patient’s Mental Illness or condition based on generally

accepted

standards of medical practice and

benchmarks.

COC.I.11.WI

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J. Nutrition

1. Individual and group nutritional counseling. This exclusion does not apply to medical nutritional education

services that are provided by appropriately licensed or registered health care professionals when both of

the following are true:

Nutritional education is required for a disease in which patient self-management is an important

component of treatment.

There exists a knowledge deficit regarding the disease which requires the intervention of a trained health

professional.

2. Enteral feedings, even if the sole source of nutrition.

3. Infant formula and donor breast milk.

4. Nutritional or cosmetic therapy using high dose or mega quantities of vitamins, minerals or elements and

other nutrition-based therapy. Examples include supplements, electrolytes and foods of any kind

(including high protein foods and low carbohydrate foods).

K. Personal Care, Comfort or Convenience

1. Television.

2.

Telephone.

3. Beauty/barber

service.

4. Guest

service.

5. Supplies, equipment and similar incidental services and supplies for personal comfort. Examples

include:

Air conditioners, air purifiers and filters and

dehumidifiers.

Batteries and battery

chargers.

Breast

pumps.

Car

seats.

Chairs, bath chairs, feeding chairs, toddler chairs, chair lifts and

recliners.

Exercise

equipment.

Home modifications such as elevators, handrails and

ramps.

Hot

tubs.

Humidifiers.

Jacuzzis.

Mattresses.

Medical alert

systems.

Motorized

beds.

Music

devices.

Personal

computers.

Pillows.

Power-operated

vehicles.

Radios.

Saunas.

Stair lifts and stair glides.

Strollers.

COC.I.11.WI

29

Safety equipment.

Treadmills.

Vehicle modifications such as van lifts.

Video players.

Whirlpools.

L. Physical Appearance

1. Cosmetic Procedures. See the definition in Section 9: Defined Terms. Examples include:

Pharmacological regimens, nutritional procedures or treatments.

Scar or tattoo removal or revision procedures (such as salabrasion, chemosurgery and other such skin

abrasion procedures).

Skin abrasion procedures performed as a treatment for acne.

Liposuction or removal of fat deposits considered undesirable, including fat accumulation under the

male breast and nipple.

Treatment for skin wrinkles or any treatment to improve the appearance of the skin.

Treatment for spider

veins.

Hair removal or replacement by any

means.

2. Replacement of an existing breast implant if the earlier breast implant was performed as a

Cosmetic

Procedure. Note: Replacement of an existing breast implant is considered reconstructive if the initial

breast

implant followed mastectomy. See

Reconstructive

Procedures in Section 1: Covered Health Services.

3. Treatment of benign gynecomastia (abnormal breast enlargement in

males).

4. Physical conditioning programs such as athletic training, body-building, exercise, fitness, flexibility

and

diversion or general

motivation.

5. Weight loss programs whether or not they are under medical supervision. Weight loss programs

for

medical reasons are also

excluded.

6. Wigs regardless of the reason for the hair

loss.

M. Procedures and Treatments

1. Excision or elimination of hanging skin on any part of the body. Examples include plastic

surgery

procedures called abdominoplasty or abdominal panniculectomy and

brachioplasty.

2. Medical and surgical treatment of excessive sweating

(hyperhidrosis).

3. Medical and surgical treatment for snoring, except when provided as a part of treatment for

documented

obstructive sleep

apnea.

4. Rehabilitation services and Manipulative Treatment to improve general physical condition that

are

provided to reduce potential risk factors, where significant therapeutic improvement is not

expected,

including routine, long-term or

maintenance/preventive treatment.

5. Speech therapy except as required for treatment of a speech impediment or speech dysfunction

that

results from Injury, stroke, cancer, Congenital Anomaly, or Autism Spectrum Disorder

Services.

6. Outpatient cognitive rehabilitation therapy except as Medically Necessary following a post-traumatic

brain

Injury or cerebral vascular

accident.

7. Psychosurgery.

8. Sex transformation operations and related services.

9. Physiological modalities and procedures that result in similar or redundant therapeutic effects when

performed on the same body region during the same visit or office encounter.

COC.I.11.WI

30

10. Biofeedback.

11. Upper and lower jawbone surgery, orthognathic surgery, and jaw alignment. This exclusion does not apply

to reconstructive jaw surgery required for Covered Persons because of a Congenital Anomaly, acute

traumatic Injury, dislocation, tumors, cancer or obstructive sleep apnea or temporomadibular joint

disorder.

12. Surgical and non-surgical treatment of obesity.

13. Stand-alone multi-disciplinary smoking cessation programs. These are programs that usually include

health care providers specializing in smoking cessation and may include a psychologist, social worker or

other licensed or certified professional. The programs usually include intensive psychological support,

behavior modification techniques and medications to control cravings.

14. Breast reduction surgery except as coverage is required by the Women’s Health and Cancer Rights Act of

1998 for which Benefits are described under

Reconstructive

Procedures in Section 1: Covered Health

Services.

15. In vitro fertilization regardless of the reason for treatment.

N. Providers

1. Services performed by a provider who is a family member by birth or marriage. Examples include a

spouse, brother, sister, parent or child. This includes any service the provider may perform on himself

or

herself.

2. Services performed by a provider with your same legal

residence.

3. Services provided at a free-standing or Hospital-based diagnostic facility without an order written by

a

Physician or other provider. Services which are self-directed to a free-standing or Hospital-bas

ed

diagnostic facility. Services ordered by a Physician or other provider who is an employee or

representative

of a free-standing or Hospital-based diagnostic facility, when that Physician or other

provider:

Has not been actively involved in your medical care prior to ordering the service,

or

Is not actively involved in your medical care after the service is

received.

This exclusion does not apply to

mammography.

O. Reproduction

1. Health services and associated expenses for infertility treatments, including assisted

reproductive

technology, regardless of the reason for the treatment. This exclusion does not apply to services

required

to treat or correct underlying causes of

infertility.

2. Surrogate parenting, donor eggs, donor sperm and host

uterus.

3. Storage and retrieval of all reproductive materials. Examples include eggs, sperm, testicular tissue

and

ovarian

tissue.

4. The reversal of voluntary

sterilization.

P. Services Provided under another Plan

1. Health services for which other coverage is required by federal, state or local law to be purchased

or

provided through other arrangements. Examples include coverage required by workers’

compensation,

no-fault auto insurance, or similar

legislation.

If coverage under workers’ compensation or similar legislation is optional for you because you could

elect

it, or could have it elected for you, Benefits will not be paid for any Injury, Sickness or Mental Illness

that

would have been covered under workers’ compensation or similar legislation had that coverage been

elected.

2. Health services for treatment of military service-related disabilities, when you are legally entitled to other

coverage and facilities are reasonably available to you.

COC.I.11.WI

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3. Health services while on active military duty.

Q. Substance Use Disorders

Exclusions listed directly below apply to services described under Substance Use Disorder Services in Section 1:

Covered Health Services.

1. Services performed in connection with conditions not classified in the current edition of the

Diagnostic

and

Statistical

Manual of the American Psychiatric Association.

2. Methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol), Cyclazocine, or their

equivalents.

3. Educational/behavioral services that are focused on primarily building skills and capabilities in

communication, social interaction and learning.

4. Services or supplies for the diagnosis or treatment of alcoholism or substance use disorders that, in the

reasonable judgment of the Mental Health/Substance Use Disorder Designee, are any of the following:

Not consistent with generally accepted standards of medical practice for the treatment of such

conditions.

Not consistent with services backed by credible research soundly demonstrating that the services or

supplies will have a measurable and beneficial health outcome, and therefore considered experimental.

Not consistent with the Mental Health/Substance Use Disorder Designee’s level of care guidelines

or

best practices as modified from time to

time.

Not clinically appropriate for the patient’s substance use disorder or condition based on

generally

accepted standards of medical practice and

benchmarks.

R. Transplants

1. Health services for organ and tissue transplants, except those described under

Transplantation

Services

in

Section 1: Covered Health Services.

2. Health services connected with the removal of an organ or tissue from you for purposes of a transplant

to

another person. (Donor costs that are directly related to organ removal are payable for a

transplant

through the organ recipient’s Benefits under the

Policy.)

3. Health services for transplants involving permanent mechanical or animal

organs.

S. Travel

1. Health services provided in a foreign country, unless required as Emergency Health

Services.

2. Travel or transportation expenses, even though prescribed by a Physician. Some travel expenses

be

reimbursed at our discretion. This exclusion does not apply to ambulance transportation for which

Benefits

are provided as described under Ambulance Services in Section 1: Covered Health Services.

T. Types of Care

1. Multi-disciplinary pain management programs provided on an inpatient basis for acute pain or

for

exacerbation of chronic

pain.

2. Custodial Care or maintenance

care.

3. Domiciliary

care.

4. Private Duty Nursing.

5. Respite care. This exclusion does not apply to respite care that is part of an integrated hospice care

program of services provided to a terminally ill person by a licensed hospice care agency for which

Benefits are provided as described under Hospice Care in Section 1: Covered Health Services.

COC.I.11.WI

32

6. Rest cures.

7. Services of personal care attendants.

8. Work hardening (individualized treatment programs designed to return a person to work or to prepare a

person for specific work).

U. Vision and Hearing

1. Purchase cost and fitting charge for eyeglasses and contact lenses.

2. Implantable lenses used only to correct a refractive error (such as Intacs corneal implants).

3. Eye exercise or vision therapy.

4. Surgery that is intended to allow you to see better without glasses or other vision correction. Examples

include radial keratotomy, laser and other refractive eye surgery.

5. Bone anchored hearing aids except when either of the following applies:

For Covered Persons with craniofacial anomalies whose abnormal or absent ear canals preclude the use

of a wearable hearing aid.

For Covered Persons with hearing loss of sufficient severity that it would not be adequately remedied by

a wearable hearing aid.

More than one bone anchored hearing aid per Covered Person who meets the above coverage

criteria

during the entire period of time the Covered Person is enrolled under the

Policy.

Repairs and/or replacement for a bone anchored hearing aid for Covered Persons who meet the

above

coverage criteria, other than for

malfunctions.

V. All Other Exclusions

1. Health services and supplies that do not meet the definition of a Covered Health Service - see the

definition

in Section 9: Defined Terms. Covered Health Services are those health services, including

services,

supplies,

or Pharmaceutical Products, which we determine to be all of the

following:

Medically

Necessary.

Described as a Covered Health Service in this

Certificate

under Section 1: Covered Health Services

and in the Schedule of Benefits.

Not otherwise excluded in this

Certificate

under Section 2: Exclusions and Limitations.

2. Physical, psychiatric or psychological exams, testing, vaccinations, immunizations or treatments that

are

otherwise covered under the Policy

when:

Required solely for purposes of school, sports or camp, travel, career or employment,

insurance,

marriage or adoption.

Related to judicial or administrative proceedings or orders.

Conducted for purposes of medical research. This exclusion does not apply to Covered Health Services

provided during a clinical trial for which Benefits are provided as described under

Clinical

Trials in

Section 1: Covered Health Services.

Required to obtain or maintain a license of any type.

3. Health services received as a result of war or any act of war, whether declared or undeclared or caused

during service in the armed forces of any country. This exclusion does not apply to Covered Persons who

are civilians Injured or otherwise affected by war, any act of war, or terrorism in non-war zones.

4. Health services received after the date your coverage under the Policy ends. This applies to all health

services, even if the health service is required to treat a medical condition that arose before the date your

coverage under the Policy ended.

COC.I.11.WI

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5. 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.

6. In the event a non-Network provider waives Copayments, Coinsurance and/or any deductible for a

particular health service, no Benefits are provided for the health service for which the Copayments,

Coinsurance and/or deductible are waived.

7. Charges in excess of Eligible Expenses or in excess of any specified limitation.

8. Long term (more than 30 days) storage. Examples include cryopreservation of tissue, blood and blood

products.

9. Autopsy.

10. Foreign language and sign language services.

11. Health services related to a non-Covered Health Service: When a service is not a Covered Health Service,

all services related to that non-Covered Health Service are also excluded. This exclusion does not apply to

services we would otherwise determine to be Covered Health Services if they are to treat complications

that arise from the non-Covered Health Service.

For the purpose of this exclusion, a "complication" is an unexpected or unanticipated condition that is

superimposed on an existing disease and that affects or modifies the prognosis of the original disease or

condition. Examples of a "complication" are bleeding or infections, following a Cosmetic Procedure, that

require

hospitalization.

COC.I.11.WI

34

How to Enroll

Section 3: When Coverage Begins

Eligible Persons must complete an enrollment form. The Enrolling Group will give the necessary forms to you.

The

Enrolling Group will then submit the completed forms to us, along with any required Premium. We will not

provide

Benefits for health services that you receive before your effective date of

coverage.

If You Are Hospitalized When Your Coverage Begins

If you are an inpatient in a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility on the day your

coverage begins, we will pay Benefits for Covered Health Services that you receive on or after your first day of

coverage related to that Inpatient Stay as long as you receive Covered Health Services in accordance with the

terms of the Policy. These Benefits are subject to any prior carrier’s obligations under state law or contract.

You should notify us of your hospitalization within 48 hours of the day your coverage begins, or as soon as is

reasonably possible. For Benefit plans that have a Network Benefit level, Network Benefits are available only if you

receive Covered Health Services from Network providers.

Who is Eligible for Coverage

The Enrolling Group determines who is eligible to enroll under the Policy and who qualifies as a

Dependent.

Eligible Person

Eligible Person usually refers to an employee or member of the Enrolling Group who meets the eligibility

rules.

When an Eligible Person actually enrolls, we refer to that person as a Subscriber. For a complete definition

of

Eligible Person, Enrolling Group and Subscriber, see Section 9: Defined Terms.

Eligible Persons must reside within the United

States.

If both spouses are Eligible Persons of the Enrolling Group, each may enroll as a Subscriber or be covered as

an

Enrolled Dependent of the other, but not

both.

Dependent

Dependent generally refers to the Subscriber’s spouse and children. When a Dependent actually enrolls, we

refer

to that person as an Enrolled Dependent. For a complete definition of Dependent and Enrolled Dependent,

see

Section 9: Defined Terms.

Dependents of an Eligible Person may not enroll unless the Eligible Person is also covered under the

Policy.

If both parents of a Dependent child are enrolled as a Subscriber, only one parent may enroll the child as

a

Dependent.

When to Enroll and When Coverage Begins

Except as described below, Eligible Persons may not enroll themselves or their Dependents.

Initial Enrollment Period

When the Enrolling Group purchases coverage under the Policy from us, the Initial Enrollment Period is the first

period of time when Eligible Persons can enroll themselves and their Dependents.

Coverage begins on the date identified in the Policy if we receive the completed enrollment form and any required

Premium within 31 days of the date the Eligible Person becomes eligible to enroll.

COC.I.11.WI

35

Open Enrollment Period

The Enrolling Group determines the Open Enrollment Period. During the Open Enrollment Period, Eligible

Persons can enroll themselves and their Dependents.

Coverage begins on the date identified by the Enrolling Group if we receive the completed enrollment form and

any required Premium within 31 days of the date the Eligible Person becomes eligible to enroll.

Dependent Child Special Open Enrollment Period

On or before the first day of the first plan year beginning on or after September 23, 2010, the Enrolling Group will

provide a 30 day dependent child special open enrollment period for Dependent children who are not currently

enrolled under the Policy and who have not yet reached the limiting age. During this dependent child special

open enrollment period, Subscribers who are adding a Dependent child and who have a choice of coverage

options will be allowed to change options.

Coverage begins on the first day of the plan year beginning on or after September 23, 2010, if we receive the

completed enrollment form and any required Premium within 31 days of the date the Dependent becomes eligible

to enroll under this special open enrollment period.

New Eligible Persons

Coverage for a new Eligible Person and his or her Dependents begins on the date agreed to by the

Enrolling

Group if we receive the completed enrollment form and any required Premium within 31 days of the date the

new

Eligible Person first becomes

eligible.

Adding New Dependents

Subscribers may enroll Dependents who join their family because of any of the following

events:

Birth.

Legal

adoption.

Placement for

adoption.

Marriage.

Legal

guardianship.

Court or administrative

order.

Coverage for the Dependent begins on the date of the event if we receive the completed enrollment form and

any

required Premium within 31 days of the event that makes the new Dependent

eligible.

In the case of a newborn infant, Coverage begins from the moment of birth and must include

Congenital

Anomalies and birth abnormalities as an Injury or

Sickness.

We must receive notification of the event and any required Premium within 60 days after the date of

birth.

If you fail to notify us and do not make any required payment beyond the 60 day period, coverage will

not

continue, unless you make all past due payments with 5 1/2% interest, within one year of the child’s birth. In

this

case, Benefits are retroactive to the date of

birth.

Special Enrollment Period

An Eligible Person and/or Dependent may also be able to enroll during a special enrollment period. A

special

enrollment period is not available to an Eligible Person and his or her Dependents if coverage under the

prior

plan was terminated for cause, or because premiums were not paid on a timely

basis.

An Eligible Person and/or Dependent does not need to elect COBRA continuation coverage to preserve

special

enrollment rights. Special enrollment is available to an Eligible Person and/or Dependent even if COBRA is not

elected.

A special enrollment period applies to an Eligible Person and any Dependents when one of the following events

occurs:

COC.I.11.WI

36

Birth.

Legal

adoption.

Placement for adoption.

Marriage.

A special enrollment period also applies for an Eligible Person and/or Dependent who did not enroll during the

Initial Enrollment Period or Open Enrollment Period if the following are true:

The Eligible Person previously declined coverage under the Policy, but the Eligible Person and/or

Dependent

becomes eligible for a premium assistance subsidy under Medicaid or Children’s Health Insurance Program

(CHIP).

Coverage will begin only if we receive the completed enrollment form and any required

Premium

within 60 days of the date of determination of subsidy

eligibility.

The Eligible Person and/or Dependent had existing health coverage under another plan at the time they had

an opportunity to enroll during the Initial Enrollment Period or Open Enrollment Period; and

Coverage under the prior plan ended because of any of the following:

Loss of eligibility (including legal separation, divorce or death).

The employer stopped paying the contributions.

In the case of

COBRA

continuation coverage, the coverage ended.

The Eligible Person and/or Dependent no longer lives or works in an HMO service area if no other

benefit option is available.

The plan no longer offers benefits to a class of individuals that include the Eligible Person and/or

Dependent.

An Eligible Person and/or Dependent incurs a claim that would exceed a lifetime limit on all benefits.

The Eligible Person and/or Dependent loses eligibility under Medicaid or

Children’s

Health Insurance

Program (CHIP). Coverage will begin only if we receive the completed enrollment form and any required

Premium within 60 days of the date coverage ended.

When an event takes place (for example, a birth, marriage or determination of eligibility for state subsidy),

coverage begins on the date of the event if we receive the completed enrollment form and any required Premium

within 31 days of the event unless otherwise noted above.

For an Eligible Person and/or Dependent who did not enroll during the Initial Enrollment Period or Open

Enrollment Period because they had existing health coverage under another plan, coverage begins on the day

immediately following the day coverage under the prior plan ends. Except as otherwise noted above, coverage

will begin only if we receive the completed enrollment form and any required Premium within 31 days of the date

coverage under the prior plan ended.

Note: In the case of a newborn, the same situation applies as noted in Adding a New Dependent above.

COC.I.11.WI

37

Section 4: When Coverage

Ends

General Information about When Coverage Ends

We may discontinue this Benefit plan and/or all similar benefit plans at any time for the reasons explained in

the

Policy, as permitted by

law.

Your entitlement to Benefits automatically ends on the date that coverage ends, even if you are hospitalized or

are

otherwise receiving medical treatment on that

date.

When your coverage ends, we will still pay claims for Covered Health Services that you received before the

date

on which your coverage ended. However, once your coverage ends, we will not pay claims for any health

services

received after that date (even if the medical condition that is being treated occurred before the date

your

coverage

ended).

Unless otherwise stated, an Enrolled Dependent’s coverage ends on the date the Subscriber’s coverage

ends.

Events Ending Your Coverage

Coverage ends on the earliest of the dates specified below:

The Entire Policy Ends

Your coverage ends on the date the Policy ends. In the event the entire Policy ends, the Enrolling Group

is

responsible for notifying you that your coverage has

ended.

You Are No Longer Eligible

Your coverage ends on the last day of the calendar month in which you are no longer eligible to be

a

Subscriber or Enrolled Dependent. Please refer to Section 9: Defined Terms for complete definitions of

the

terms "Eligible Person," "Subscriber," "Dependent" and "Enrolled

Dependent."

We Receive Notice to End Coverage

Your coverage ends on the last day of the calendar month in which we receive written notice from the

Enrolling Group instructing us to end your coverage, or the date requested in the notice, if later. The

Enrolling Group is responsible for providing written notice to us to end your coverage.

Subscriber Retires or Is Pensioned

Your coverage ends the last day of the calendar month in which the Subscriber is retired or

receiving

benefits under the Enrolling Group’s pension or retirement plan. The Enrolling Group is responsible

for

providing written notice to us to end your

coverage.

This provision applies unless a specific coverage classification is designated for retired or

pensioned

persons in the Enrolling Group’s application, and only if the Subscriber continues to meet any

applicable

eligibility requirements. The Enrolling Group can provide you with specific information about

what

coverage is available for retirees.

Other Events Ending Your Coverage

When either of the following happens, we will provide advance written notice to the Subscriber that coverage

will

end on the date we identify in the

notice:

Fraud or Intentional Misrepresentation of a Material Fact

You committed an act, practice, or omission that constituted fraud, or an intentional misrepresentation of

a material fact. Examples include false information relating to another person’s eligibility or status as a

Dependent.

During the first two years the Policy is in effect, we have the right to demand that you pay back all Benefits

we paid to you, or paid in your name, during the time you were incorrectly covered under the Policy. After

the first two years, we can only demand that you pay back these Benefits if the written application

contained a fraudulent misstatement.

Threatening Behavior

COC.I.11.WI

38

You committed acts of physical or verbal abuse that pose a threat to our staff.

Coverage for a Disabled Dependent Child

Coverage for an unmarried Enrolled Dependent child who is disabled will not end just because the child

has

reached a certain age. We will extend the coverage for that child beyond the limiting age if both of the

following

are true regarding the Enrolled Dependent

child:

Is not able to be self-supporting because of mental or physical handicap or disability.

Depends mainly on the Subscriber for support.

Coverage will continue as long as the Enrolled Dependent is medically certified as disabled and dependent unless

coverage is otherwise terminated in accordance with the terms of the Policy.

We will ask you to furnish us with proof of the medical certification of disability within 31 days of the date

coverage would otherwise have ended because the child reached a certain age. Before we agree to this extension

of coverage for the child, we may require that a Physician chosen by us examine the child. We will pay for that

examination.

We may continue to ask you for proof that the child continues to be disabled and dependent. Such proof might

include medical examinations at our expense. However, we will not ask for this information more than once a

year, after the two-year period immediately following the time the child reaches the limiting age.

If you do not provide proof of the child’s disability and dependency within 31 days of our request as described

above, coverage for that child will end.

Extended Coverage for Total Disability

Coverage for a Covered Person who is Totally Disabled on the date the entire Policy is terminated will not

end

automatically. We will temporarily extend the coverage, only for treatment of the condition causing the

Total

Disability. Benefits will be paid until the earlier of either of the

following:

The Total Disability ends.

Twelve months from the date coverage would have ended when the entire Policy was

terminated.

The

maximum Benefit is

paid.

The succeeding insurer’s policy provides coverage for the condition(s) causing the Total Disability.

Continuation of Coverage and Conversion

If your coverage ends under the Policy, you may be entitled to elect continuation coverage (coverage

that

continues on in some form) in accordance with federal or state

law.

Continuation coverage under COBRA (the federal Consolidated Omnibus Budget Reconciliation Act) is

available

only to Enrolling Groups that are subject to the terms of COBRA. You can contact your plan administrator

to

determine if your Enrolling Group is subject to the provisions of

COBRA.

If you selected continuation coverage under a prior plan which was then replaced by coverage under the

Policy,

continuation coverage will end as scheduled under the prior plan or in accordance with federal or state

law,

whichever is

earlier.

We are not the Enrolling Group’s designated "plan administrator" as that term is used in federal law, and we

do

not assume any responsibilities of a "plan administrator" according to federal

law.

We are not obligated to provide continuation coverage to you if the Enrolling Group or its plan administrator

fails

to perform its responsibilities under federal law. Examples of the responsibilities of the Enrolling Group or its

plan

administrator

are:

Notifying you in a timely manner of the right to elect continuation

coverage.

Notifying us in a timely manner of your election of continuation coverage.

COC.I.11.WI

39

Qualifying Events for Continuation Coverage under State Law

If your coverage is terminated due to one of the qualifying events listed below and you were continuously

covered

under the Policy for a period of at least three months, you may elect to continue coverage, including that of

any

eligible

Dependents.

Reduction of hours or termination of the Subscriber from employment with the Enrolling Group for any

reason except gross misconduct.

Termination of coverage due to the death of the Subscriber.

Termination of coverage due to an annulment or divorce from the

Subscriber.

Notification Requirements and Election Period for Continuation Coverage

under State Law

The Enrolling Group will provide you with written notification of the right to continuation coverage within five days

of when the Enrolling Group receiving notice to terminate coverage. You must elect continuatio n coverage within

30 days of receiving this notification or 30 days after the qualifying event. You should obtain an election form from

the Enrolling Group or the employer and, once election is made, forward all monthly Premiums to the Enrolling

Group for payment to us.

Terminating Events for Continuation Coverage under State Law

Continuation coverage under the Policy will end on the earliest of the following

dates:

The date the Covered Person establishes residence outside of the

state.

18 months from the date your continuation

began.

The date coverage ends for failure to make timely payment of the Premium.

For

the spouse, the date the Subscriber’s group coverage

ends.

The date coverage is or could be obtained under any other group health

plan.

The

date the Policy ends.

Conversion

If your coverage terminates for one of the reasons described below, you may apply for conversion

coverage

without furnishing evidence of

insurability.

Reasons for

termination:

The Subscriber is retired or pensioned.

You cease to be eligible as a Subscriber or Enrolled

Dependent.

Continuation coverage

ends.

The entire Policy ends and is not replaced.

Application and payment of the initial Premium must be made within 31 days after coverage ends under

the

Policy. Conversion coverage will be issued in accordance with the terms and conditions in effect at the time

of

application. Conversion coverage may be substantially different from coverage provided under the

Policy.

COC.I.11.WI

40

Section 5: How to File a Claim

If You Receive Covered Health Services from a Network Provider

We pay Network providers directly for your Covered Health Services. If a Network provider bills you for

any

Covered Health Service, contact us. However, you are responsible for meeting any applicable deductible and

for

paying any required Copayments and Coinsurance to a Network provider at the time of service, or when

you

receive a bill from the

provider.

Continuity of Care

If a provider’s participation in the network has terminated, we will cover services, if we present the provider as a

member of the network in the marketing materials that are provided or available at the most recent open

enrollment period.

If you are undergoing a course of treatment with a Network provider who is no longer available, we will provide

coverage for the remainder of the course of treatment or 90 days, whichever is shorter. If maternity care is the

course of treatment and the Covered Person is in their 2nd or 3rd trimester of pregnancy, we will provide

coverage until the completion of postpartum care for the mother and infant.

Coverage will not be provided, if the provider no longer practices in the Service Area or we terminate the

provider’s contract for misconduct on his/her part.

If You Receive Covered Health Services from a Non-Network Provider

When you receive Covered Health Services from a non-Network provider, you are responsible for

requesting

payment from us. You must file the claim in a format that contains all of the informatio n we require, as

described

below.

You should submit a request for payment of Benefits within 90 days after the date of service. If you don’t

provide

this information to us within 15 months of the date of service, Benefits for that health service will be denied

or

reduced, in our discretion. This time limit does not apply if you are legally incapacitated. If your claim relates

to

an Inpatient Stay, the date of service is the date your Inpatient Stay

ends.

Required Information

When you request payment of Benefits from us, you must provide us with all of the following

information:

The Subscriber’s name and

address.

The patient’s name and age.

The number stated on your ID

card.

The name and address of the provider of the

service(s).

The

name and address of any ordering

Physician.

A diagnosis from the Physician.

An itemized bill from your provider that includes the Current Procedural Terminology (CPT) codes or

a

description of each

charge.

The date the Injury or Sickness

began.

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 of the other

carrier(s).

The above information should be filed with us at the address on your ID card.

COC.I.11.WI

41

Payment of Benefits

You may not assign your Benefits under the Policy to a non-Network provider without our consent. When

an

assignment is not obtained, we will send the reimbursement directly to you (the Subscriber) for you to

reimburse

them upon receipt of their bill. We may, however, in our discretion, pay a non-Network provider directly

for

services rendered to you. In the case of any such assignment of Benefits or payment to a non-Network

provider,

we reserve the right to offset Benefits to be paid to the provider by any amounts that the provider owes

us.

When you assign your Benefits under the Policy to a non-Network provider with our consent, and

the

non-Network provider submits a claim for payment, you and the non-Network provider represent and warrant

the

following:

The Covered Health Services were actually provided.

The Covered Health Services were medically appropriate.

COC.I.11.WI

42

Section 6: Questions, Complaints and

Grievances

The following terms apply to this section:

Complaint - your expression of dissatisfaction with us or any Network provider.

Expedited Grievance - a Grievance where any of the following applies:

The duration of the standard resolution process will result in serious jeopardy to your life or health or your

ability to regain maximum control.

In the opinion of a Physician with knowledge of your condition, you are subject to severe pain that cannot

be

adequately managed without the care or treatment that is the subject of the

Grievance.

A Physician with knowledge of your condition determines that the Grievance should be treated as an

Expedited Grievance.

Grievance - a dissatisfaction with our administration, claims practices or provision of services that is expressed in

writing, to us by you or on your behalf.

To resolve a question, complaint, or grievance, just follow these steps:

What to Do if You Have a Question

Contact Customer Care at the telephone number shown on your ID card. Customer Care representatives

are

available to take your call during regular business hours, Monday through

Friday.

What to Do if You Have a Complaint

Contact Customer Care at the telephone number shown on your ID card. Customer Care and attempt to address

your complaint through formal discussion representatives are available to take your call during regular business

hours, Monday through Friday.

If you would rather send your complaint to us in writing, the Customer Care

representati

ve can provide you with

the appropriate address.

If the Customer Care representative cannot resolve the issue to your satisfaction over the phone, he/she can help

you prepare and submit a written complaint. We will notify you of our decision regarding your complaint within 30

days of receiving it.

Grievance Process

Each time we deny a claim or Benefit or initiate disenrollment proceedings, we will notify you of your right to file

a

grievance.

We will acknowledge a grievance, in writing, within five business days of its receipt and resolve the

grievance

within 30 calendar days of its receipt. If we are unable to resolve the grievance within that time, we will extend

the

time period by an additional 30 calendar days. If you receive notification that the grievance has not

been

resolved, additional time is needed and the expected date the grievance will be

resolved.

You or an authorized representative have the right to appear in person before the grievance committee to

present

written or oral information. We will notify you, in writing, of the time and place of the meeting at least

seven

calendar days before the

meeting.

Following a review of your grievance, you will receive a written notification of the committee’s decision, along

with

the titles of the people on the grievance

committee.

What to Do if Your Grievance Requires Immediate Action

In situations where the normal duration of the grievance process could have adverse effects on you, a grievance

will not need to be submitted in writing. Instead, you or your Physician should contact us as soon as possible. We

will resolve the grievance within 72 hours of its receipt, unless more information is needed. If more information is

needed, we will notify you of our decision by the end of the next business day following the receipt of the required

information.

COC.I.11.WI

43

The complaint process for urgent situations does not apply to prescheduled treatments, therapies, surgeries or

other procedures that we do not consider urgent situations.

What to Do if You Disagree with Our Decision

You may resolve your problem by taking the steps outlined above in the Grievance process. You may

also

contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which enforces

Wisconsin’s

insurance laws, and file a complaint. You can contact the OFFICE OF THE COMMISSIONER OF INSURANCE

by

writing

to:

Office of the Commissioner of

Insurance

Complaints

Department

P.O. Box

7873

Madison, WI

53707-7873

or you can call (800)236-8517 (outside of Madison) or (608)266-0103 in Madison or email them

at

complaints@ociwi.state.us

and request a complaint

form.

Please note that our decision is based only on whether or not Benefits are available under the Policy. We do

not

determine whether the pending health service is necessary or appropriate. That decision is between you and

your

Physician.

External Review Program

You or your authorized representative may request and obtain an external review of a medical adverse

determination or the exclusion for Experimental, Investigational or Unproven Services, preexisting condition

exclusion denial determinations, and the rescission of a policy or certificate after exhausting the internal

Grievance process. In order to request an external review, the expected cost of the non-covered or terminated

treatment or payment must be in accordance with the requirements set forth in Wisconsin Ins. 18.105. The

request must be made in writing within four months of the date of the determination or within 4 months of the

completion of the internal Grievance process, whichever is later.

The external review will be conducted by an independent review organization (IRO). You or your authorized

representative must select an IRO from the list of IROs certified by the Office of the Commissioner of Insurance. In

addition, your written request must contain the name of the IRO selected.

You will not have to exhaust the internal Grievance process before requesting an external review, if either of the

following apply:

All parties agree that the matter may proceed directly to the external review;

or

The independent review organization determines that proceeding through the internal Grievance

process

before an external review would jeopardize your life and health or ability to regain maximum

function.

If the external review is not terminated, the independent review organization shall make a decision based on

any documents and information submitted, within 30 business days after the expiration of all time limits that

apply in this matter. If it is determined that following the normal external review process would

jeopardize

your life and health or your ability to regain maximum function, the independent review organization

shall

make a decision within 72 hours, after the expiration of the time limits that apply in this

matter.

Any decision made by the independent review organization is binding on both parties involved, unless it is

regarding a preexisting condition exclusion denial determination or a rescission it is not binding.

Contact us at the telephone number shown on your ID card for more information on the external review program

or for a current listing of independent review organizations.

For purposes of this section coverage denial determination is an adverse determination, an Experimental,

Investigational, or Unproven Service, a Preexisting Condition exclusion denial determination, or the rescission of

a policy or certificate.

Preexisting condition exclusion is a determination by or on behalf of an insurer that issues a health benefit plan

denying or terminating treatment or payment for treatment on the basis of a Preexisting Condition exclusion.

COC.I.11.WI

44

Adverse determination means a determination by or on behalf of an insurer that issues a health benefit plan to

which all of the following apply:

An admission to a health care facility, the availability of care, the continued stay or other treatment that is a

covered benefit has been reviewed.

The treatment does not meet the health benefit plan’s requirement for medical necessity,

appropriateness,

health care setting, level of care or

effectiveness.

The health benefit plan reduced, denied or terminated the treatment or payment for the treatment.

The amount of the reduction or the cost or expected cost of the denied or terminated treatment or payment

exceeds, or will exceed during the course of treatment, of the requirements set forth under Wisconsin INS

18.105.

COC.I.11.WI

45

Section 7: Coordination of Benefits

Benefits When You Have Coverage under More than One Plan

This section describes how Benefits under the Policy will be coordinated with those of any other plan

that

provides benefits to you. The language in this section is from model laws drafted by the National Association of

Insurance

Commissioners

(NAIC) and represents standard industry practice for coordinating

benefits.

When Coordination of Benefits Applies

This coordination of benefits (COB) provision applies when a person has health care coverage under more than

one Plan. Plan is defined below.

The order of benefit determination rules below govern the order in which each Plan will pay a claim for benefits.

The Plan that pays first is called the Primary Plan. The Primary Plan must pay benefits in accordance with its

policy terms without regard to the possibility that another Plan may cover some expenses. The Plan that pays

after the Primary Plan is the Secondary Plan. The Secondary Plan may reduce the benefits it pays so that

payments from all Plans do not exceed 100% of the total Allowable Expense.

Definitions

For purposes of this section, terms are defined as

follows:

A. A Plan is any of the following that provides benefits or services for medical, pharmacy or dental care

or

treatment. If separate contracts are used to provide coordinated coverage for members of a group,

the

separate contracts are considered parts of the same plan and there is no COB among those

separate

contracts.

1. Plan includes: group and non-group insurance contracts, health maintenance organization

(HMO)

contracts, closed panel plans or other forms of group or group-type coverage (whether insured

or

uninsured); medical care components of long-term care contracts, such as skilled nursing

care;

medical benefits under group or individual automobile contracts; and Medicare or any other

federal

governmental plan, as permitted by

law.

2. Plan does not include: hospital indemnity coverage insurance or other fixed indemnity

coverage;

accident only coverage; specified disease or specified accident coverage; limited benefit

health

coverage, as defined by state law; school accident type coverage; benefits for

non-medical

components of long-term care policies; Medicare supplement policies; Medicaid policies;

or

coverage under other federal governmental plans, unless permitted by

law.

Each contract for coverage under 1. or 2. above is a separate Plan. If a Plan has two parts and COB

rules

apply only to one of the two, each of the parts is treated as a separate

Plan.

B. This Plan means, in a COB provision, the part of the contract providing the health care benefits to

which

the

COB provision applies and which may be reduced because of the benefits of other plans. Any

other

part

of the contract providing health care benefits is separate from This Plan. A contract may apply

one

COB provision to certain benefits, such as dental benefits, coordinating only with similar benefits, and

may

apply another COB provision to coordinate other

benefits.

C. The order of benefit determination rules determine whether This Plan is a Primary Plan or Secondary

Plan

when the person has health care coverage under more than one Plan. When This Plan is primary,

it

determines payment for its benefits first before those of any other Plan without considering any

other

Plan’s benefits. When This Plan is secondary, it determines its benefits after those of another Plan and

may

reduce the benefits it pays so that all Plan benefits do not exceed 100% of the total Allowable

Expense.

D. Allowable Expense is a health care expense, including deductibles, coinsurance and copayments , that

is

covered at least in part by any Plan covering the person. When a Plan provides benefits in the form of

services, the reasonable cash value of each service will be considered an Allowable Expense and a benefit

paid. An expense that is not covered by any Plan covering the person is not an Allowable Expense. In

addition, any expense that a provider by law or in accordance with a contractual agreement is prohibited

from charging a Covered Person is not an Allowable Expense.

COC.I.11.WI

46

The following are examples of expenses or services that are not Allowable Expenses:

1. The difference between the cost of a semi-private hospital room and a private room is not an

Allowable Expense unless one of the Plans provides coverage for private hospital room expenses.

2. If a person is covered by two or more Plans that compute their benefit payments on the basis of

usual and customary fees or relative value schedule reimbursement methodology or other similar

reimbursement methodology, any amount in excess of the highest reimbursement amount for a

specific benefit is not an Allowable Expense.

3. If a person is covered by two or more Plans that provide benefits or services on the basis of

negotiated fees, an amount in excess of the highest of the negotiated fees is not an Allowable

Expense.

4. If a person is covered by one Plan that calculates its benefits or services on the basis of usual and

customary fees or relative value schedule reimbursement methodology or other similar

reimbursement methodology and another Plan that provides its benefits or services on the basis of

negotiated fees, the Primary Plan’s payment arrangement shall be the Allowable Expense for all

Plans. However, if the provider has contracted with the Secondary Plan to provide the benefit or

service for a specific negotiated fee or payment amount that is different than the Primary Plan’s

payment arrangement and if the provider’s contract permits, the negotiated fee or payment shall be

the Allowable Expense used by the Secondary Plan to determine its benefits.

5. The amount of any benefit reduction by the Primary Plan because a Covered Person has failed

to

comply with the Plan provisions is not an Allowable Expense. Examples of these types of

plan

provisions include second surgical opinions, precertification of admissions and preferred

provider

arrangements.

E. Closed Panel Plan is a Plan that provides health care benefits to Covered Persons primarily in the form

of

services through a panel of providers that have contracted with or are employed by the Plan, and

that

excludes benefits for services provided by other providers, except in cases of emergency or referral by

a

panel

member.

F. Custodial Parent is the parent awarded custody by a court decree or, in the absence of a court decree,

is

the parent with whom the child resides more than one half of the calendar year excluding any

temporary

visitation.

Order of Benefit Determination Rules

When a person is covered by two or more Plans, the rules for determining the order of benefit payments are

as

follows:

A. The Primary Plan pays or provides its benefits according to its terms of coverage and without regard to

the

benefits under any other

Plan.

B. Except as provided in the next paragraph, a Plan that does not contain a coordination of

benefits

provision that is consistent with this provision is always primary unless the provisions of both Plans

state

that the complying plan is primary.

Coverage that is obtained by virtue of membership in a group that is designed to supplement a part of a

basic package of benefits and provides that this supplementary coverage shall be in excess of any other

parts of the Plan provided by the contract holder. Examples of these types of situations are major medical

coverages that are superimposed over base plan hospital and surgical benefits and insurance type

coverages that are written in connection with a Closed Panel Plan to provide out-of-network benefits.

C. A Plan may consider the benefits paid or provided by another Plan in determining its benefits only when it

is secondary to that other Plan.

D. Each Plan determines its order of benefits using the first of the following rules that apply:

1. Non-Dependent or Dependent. The Plan that covers the person other than as a dependent, for

example as an employee, member, policyholder, subscriber or retiree is the Primary Plan and the

Plan that covers the person as a dependent is the Secondary Plan. However, if the person is a

Medicare beneficiary and, as a result of federal law, Medicare is secondary to the Plan covering the

person as a dependent; and primary to the Plan covering the person as other than a dependent

COC.I.11.WI

47

(e.g. a retired employee); then the order of benefits between the two Plans is reversed so that the

Plan covering the person as an employee, member, policyholder, subscriber or retiree is the

Secondary Plan and the other Plan is the Primary Plan.

2. Dependent Child Covered Under More Than One Coverage Plan. Unless there is a court decree

stating otherwise, plans covering a dependent child shall determine the order of benefits as follows:

a) For a dependent child whose parents are married or are living together, whether or not they

have ever been married:

(1) The Plan of the parent whose birthday falls earlier in the calendar year is the Primary Plan;

or

(2) If both parents have the same birthday, the Plan that covered the parent longest is the

Primary Plan.

b) For a dependent child whose parents are divorced or separated or are not living together,

whether or not they have ever been married:

(1) If a court decree states that one of the parents is responsible for the dependent child’s

health care expenses or health care coverage and the Plan of that parent has actual

knowledge of those terms, that Plan is primary. If the parent with responsibility has no

health care coverage for the dependent child’s health care expenses, but that parent’s

spouse does, that parent’s spouse’s plan is the Primary Plan. This shall not apply with

respect to any plan year during which benefits are paid or provided before the entity

has

actual knowledge of the court decree

provision.

(2) If a court decree states that both parents are responsible for the dependent child’s

health

care expenses or health care coverage, the provisions of subparagraph a) above

shall

determine the order of

benefits.

(3) If a court decree states that the parents have joint custody without specifying that

one

parent has responsibility for the health care expenses or health care coverage of

the

dependent child, the provisions of subparagraph a) above shall determine the order

of

benefits.

(4) If there is no court decree allocating responsibility for the child’s health care expenses

or

health care coverage, the order of benefits for the child are as

follows:

(a) The Plan covering the Custodial

Parent.

(b) The Plan covering the Custodial Parent’s

spouse.

(c) The Plan covering the non-Custodial

Parent.

(d) The Plan covering the non-Custodial Parent’s

spouse.

c) For a dependent child covered under more than one plan of individuals who are not

the

parents of the child, the order of benefits shall be determined, as applicable,

under

subparagraph a) or b) above as if those individuals were parents of the

child.

3. Active Employee or Retired or Laid-off Employee. The Plan that covers a person as an

active

employee, that is, an employee who is neither laid off nor retired is the Primary Plan. The

same

would hold true if a person is a dependent of an active employee and that same person is

a

dependent of a retired or laid-off employee. If the other Plan does not have this rule, and, as

a

result, the Plans do not agree on the order of benefits, this rule is ignored. This rule does not apply

if

the rule labeled D.1. can determine the order of

benefits.

4. COBRA or State Continuation Coverage. If a person whose coverage is provided pursuant

to

COBRA or under a right of continuation provided by state or other federal law is covered

under

another Plan, the Plan covering the person as an employee, member, subscriber or retiree

or

covering the person as a dependent of an employee, member, subscriber or retiree is the Primary

Plan, and the

COBRA

or state or other federal continuation coverage is the Secondary Plan. If the

other Plan does not have this rule, and as a result, the Plans do not agree on the order of benefits,

COC.I.11.WI

48

this rule is ignored. This rule does not apply if the rule labeled D.1. can determine the order of

benefits.

5. Longer or Shorter Length of Coverage. The Plan that covered the person as an employee, member,

policyholder, subscriber or retiree longer is the Primary Plan and the Plan that covered the person

the shorter period of time is the Secondary Plan.

6. If the preceding rules do not determine the order of benefits, the Allowable Expenses shall be

shared equally between the Plans meeting the definition of Plan. In addition, This Plan will not pay

more than it would have paid had it been the Primary Plan.

Effect on the Benefits of This Plan

A. When This Plan is secondary, it may reduce its benefits so that the total benefits paid or provided by

all

Plans are not more than the total Allowable Expenses. In determining the amount to be paid for any

claim,

the Secondary Plan will calculate the benefits it would have paid in the absence of other health

care

coverage and apply that calculated amount to any Allowable Expense under its Plan that is unpaid by

the

Primary Plan. The Secondary Plan may then reduce its payment by the amount so that, when

combined

with the amount paid by the Primary Plan, the total benefits paid or provided by all Plans for the claim

do

not exceed the total Allowable Expense for that claim. In addition, the Secondary Plan shall credit to

its

plan deductible any amounts it would have credited to its deductible in the absence of other health

care

coverage.

B. If a Covered Person is enrolled in two or more Closed Panel Plans and if, for any reason, including

the

provision of service by a non-panel provider, benefits are not payable by one Closed Panel Plan,

COB

shall not apply between that Plan and other Closed Panel

Plans.

Right to Receive and Release Needed Information

Certain facts about health care coverage and services are needed to apply these COB rules and to determine

benefits payable under This Plan and other Plans. We may get the facts we need from, or give them to, other

organizations or persons for the purpose of applying these rules and determining benefits payable under This

Plan and other Plans covering the person claiming benefits.

We need not tell, or get the consent of, any person to do this. Each person claiming benefits under This Plan must

give us any facts we need to apply those rules and determine benefits payable. If you do not provide us the

information we need to apply these rules and determine the Benefits payable, your claim for Benefits will be

denied.

Payments Made

A payment made under another Plan may include an amount that should have been paid under This Plan. If

it

does, we may pay that amount to the organization that made the payment. That amount will then be treated

as

though it were a benefit paid under This Plan. We will not have to pay that amount again. The term

"payment

made" includes providing benefits in the form of services, in which case "payment made" means reasonable

cash

value of the benefits provided in the form of

services.

Right of Recovery

If the amount of the payments we made is more than we should have paid under this COB provision, we may

recover the excess from one or more of the persons we have paid or for whom we have paid; or any other person

or organization that may be responsible for the benefits or services provided for you. The "amount of the

payments made" includes the reasonable cash value of any benefits provided in the form of services.

When Medicare is Secondary

If you have other health insurance which is determined to be primary to Medicare, then Benefits payable

under

This Plan will be based on Medicare’s reduced benefits. In no event will the combined benefits paid under

these

coverages exceed the total Medicare Eligible Expense for the service or

item.

COC.I.11.WI

49

Section 8: General Legal Provisions

Your Relationship with Us

In order to make choices about your health care coverage and treatment, we believe that it is important for you

to

understand how we interact with your Enrolling Group’s Benefit plan and how it may affect you. We help

finance

or administer the Enrolling Group’s Benefit plan in which you are enrolled. We do not provide medical services

or

make treatment decisions. This

means:

We communicate to you decisions about whether the Enrolling Group’s Benefit plan will cover or pay for the

health care that you may receive. The plan pays for Covered Health Services, which are more fully described

in this Certificate.

The plan may not pay for all treatments you or your Physician may believe are necessary. If the plan does

not pay, you will be responsible for the cost.

We may use individually identifiable information about you to identify for you (and you alone) procedures,

products or services that you may find valuable. We will use individually identifiable information about you as

permitted or required by law, including in our operations and in our research. We will use de-identified data for

commercial purposes including research.

Please refer to our Notice of Privacy Practices for details.

Our Relationship with Providers and Enrolling Groups

The relationships between us and Network providers and Enrolling Groups are solely contractual

relationships

between independent contractors. Network providers and Enrolling Groups are not our agents or

employees.

Neither we nor any of our employees are agents or employees of Network providers or the Enrolling

Groups.

We do not provide health care services or supplies, nor do we practice medicine. Instead, we arrange for

health

care providers to participate in a Network and we pay Benefits. Network providers are independent

practitioners

who run their own offices and facilities. Our credentialing process confirms public information about

the

providers’ licenses and other credentials, but does not assure the quality of the services provided. They are

not

our employees nor do we have any other relationship with Network providers such as principal-agent or

joint

venture. We are not liable for any act or omission of any

provider.

We are not considered to be an employer for any purpose with respect to the administration or provision

of

benefits under the Enrolling Group’s Benefit plan. We are not responsible for fulfilling any duties or obligations

of

an employer with respect to the Enrolling Group’s Benefit

plan.

The Enrolling Group is solely responsible for all of the

following:

Enrollment and classification changes (including classification changes resulting in your enrollment or the

termination of your coverage).

The timely payment of the Policy Charge to

us.

Notifying you of the termination of the

Policy.

When the Enrolling Group purchases the Policy to provide coverage under a benefit plan governed by

the

Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001 et seq., we are not the plan administrator

or

named fiduciary of the benefit plan, as those terms are used in ERISA. If you have questions about your

welfare

benefit plan, you should contact the Enrolling Group. If you have any questions about this statement or

about

your rights under ERISA, contact the nearest area office of the Employee Benefits Security Administration, U. S.

Department of Labor.

COC.I.11.WI

50

Your Relationship with Providers and Enrolling Groups

The relationship between you and any provider is that of provider and

patient.

You are responsible for choosing your own provider.

You are responsible for paying, directly to your provider, any amount identified as a member responsibility,

including Copayments, Coinsurance, any deductible and any amount that exceeds Eligible Expenses.

You are responsible for paying, directly to your provider, the cost of any non-Covered Health

Service.

You must decide if any provider treating you is right for you. This includes Network providers you choose

and providers to whom you have been

referred.

You must decide with your provider what care you should receive.

Your provider is solely responsible for the quality of the services provided to

you.

The relationship between you and the Enrolling Group is that of employer and employee, Dependent or

other

classification as defined in the

Policy.

Notice

When we provide written notice regarding administration of the Policy to an authorized representative of the

Enrolling Group, that notice is deemed notice to all affected Subscribers and their Enrolled Dependents. The

Enrolling Group is responsible for giving notice to you.

Statements by Enrolling Group or Subscriber

All statements made by the Enrolling Group or by a Subscriber shall, in the absence of fraud, be

deemed

representations and not warranties. Except for fraudulent statements, we will not use any statement made by

the

Enrolling Group to void the Policy after it has been in force for a period of two

years.

Incentives to Providers

We pay Network providers through various types of contractual arrangements, some of which may

include

financial incentives to promote the delivery of health care in a cost efficient and effective manner. These

financial

incentives are not intended to affect your access to health

care.

Examples of financial incentives for Network providers

are:

Bonuses for performance based on factors that may include quality, member satisfaction

and/or

cost-effectiveness.

Capitation - a group of Network providers receives a monthly payment from us for each Covered Person who

selects a Network provider within the group to perform or coordinate certain health services. The Network

providers receive this monthly payment regardless of whether the cost of providing or arranging to provide

the Covered Person’s health care is less than or more than the payment.

We use various payment methods to pay specific Network providers. From time to time, the payment method

may change. If you have questions about whether your Network provider’s contract with us includes any

financial

incentives, we encourage you to discuss those questions with your provider. You may also contact us at

the

telephone number on your ID card. We can advise whether your Network provider is paid by any

financial

incentive, including those listed above; however, the specific terms of the contract, including rates of

payment,

are confidential and cannot be

disclosed.

Incentives to You

Sometimes we may offer coupons or other incentives to encourage you to participate in various

wellness

programs or certain disease management programs. The decision about whether or not to participate is

yours

alone but we recommend that you discuss participating in such programs with your Physician. These

incentives

are not Benefits and do not alter or affect your Benefits. Contact us if you have any questions.

COC.I.11.WI

51

Rebates and Other Payments

We may receive rebates for certain drugs that are administered to you in your home or in a Physician’s office,

or

at a Hospital or Alternate Facility. This includes rebates for those drugs that are administered to you before

you

meet any applicable deductible. We do not pass these rebates on to you, nor are they applied to any

deductible

or taken into account in determining your Copayments or

Coinsurance.

Interpretation of Benefits

We have the sole and exclusive discretion to do all of the following:

Interpret Benefits under the

Policy.

Interpret the other terms, conditions, limitations and exclusions set out in the Policy, including this Certificate,

the Schedule of Benefits and any Riders and/or

Amendments.

Make factual determinations related to the Policy and its Benefits.

We may delegate this discretionary authority to other persons or entities that provide services in regard to the

administration of the Policy.

In certain circumstances, for purposes of overall cost savings or efficiency, we may, in our discretion, offer

Benefits for services that would otherwise not be Covered Health Services. The fact that we do so in any particular

case shall not in any way be deemed to require us to do so in other similar cases.

Administrative Services

We may, in our sole discretion, arrange for various persons or entities to provide administrative services in

regard

to the Policy, such as claims processing. The identity of the service providers and the nature of the services

they

provide may be changed from time to time in our sole discretion. We are not required to give you prior notice

of

any such change, nor are we required to obtain your approval. You must cooperate with those persons or

entities

in the performance of their

responsibilities.

Amendments to the Policy

To the extent permitted by law, we reserve the right, in our sole discretion and without your approval, to

change,

interpret, modify, withdraw or add Benefits or terminate the

Policy.

Any provision of the Policy which, on its effective date, is in conflict with the requirements of state or

federal

statutes or regulations (of the jurisdiction in which the Policy is delivered) is hereby amended to conform to

the

minimum requirements of such statutes and

regulations.

No other change may be made to the Policy unless it is made by an Amendment or Rider which has been

signed

by one of our officers. All of the following conditions

apply:

Amendments to the Policy are effective 31 days after we send written notice to the Enrolling

Group.

Amendments that result in a reduction of Benefits will be effective upon 60 days prior written

notice.

Riders are effective on the date we specify.

No agent has the authority to change the Policy or to waive any of its provisions.

No one has authority to make any oral changes or amendments to the

Policy.

Information and Records

We may use your individually identifiable health information to administer the Policy and pay claims, to identify

procedures, products, or services that you may find valuable, and as otherwise permitted or required by law. We

may request additional information from you to decide your claim for Benefits. We will keep this information

confidential. We may also use your de-identified data for commercial purposes, including research, as permitted

by law. More detail about how we may use or disclose your information is found in our Notice of Privacy

Practices.

By accepting Benefits under the Policy, you authorize and direct any person or institution that has provided

services to you to furnish us with all information or copies of records relating to the services provided to you. We

have the right to request this information at any reasonable time. This applies to all Covered Persons, including

COC.I.11.WI

52

Enrolled Dependents whether or not they have signed the Subscriber’s enrollment form. We agree that such

information and records will be considered confidential.

We have the right to release any and all records concerning health care services which are necessary to

implement and administer the terms of the Policy, for appropriate medical review or quality assessment, or as we

are required to do by law or regulation. During and after the term of the Policy, we and our related entities may

use and transfer the information gathered under the Policy in a de-identified format for commercial purposes,

including research and analytic purposes. Please refer to our Notice of Privacy Practices.

For complete listings of your medical records or billing statements we recommend that you contact your health

care provider. Providers may charge you reasonable fees to cover their costs for providing records or completing

requested forms.

If you request medical forms or records from us, we also may charge you reasonable fees to cover costs for

completing the forms or providing the records.

In some cases, as permitted by law, we will designate other persons or entities to request records or information

from or related to you, and to release those records as necessary. Our designees have the same rights to this

information as we have.

Examination of Covered Persons

In the event of a question or dispute regarding your right to Benefits, we may require that a Network Physician

of

our choice examine you at our

expense.

Workers’ Compensation not Affected

Benefits provided under the Policy do not substitute for and do not affect any requirements for coverage by

workers’ compensation insurance.

Subrogation and Reimbursement

Subrogation is the substitution of one person or entity in the place of another with reference to a lawful

claim,

demand or right. Immediately upon paying or providing any Benefit, we shall be subrogated to and shall

succeed

to all rights of recovery, under any legal theory of any type for the reasonable value of any services and

Benefits

we provided to you, from any or all of the following listed

below.

In addition to any subrogation rights and in consideration of the coverage provided by this Certificate, we

shall

also have an independent right to be reimbursed by you for the reasonable value of any services and Benefits

we

provide to you, from any or all of the following listed

below.

Third parties, including any person alleged to have caused you to suffer injuries or damages.

Your

employer.

Any person or entity who is or may be obligated to provide benefits or payments to you, including benefits

or

payments for underinsured or uninsured motorist protection, no-fault or traditional auto insurance,

medical

payment coverage (auto, homeowners or otherwise), workers’ compensation coverage, other

insurance

carriers or third party

administrators.

Any person or entity who is liable for payment to you on any equitable or legal liability

theory.

These third parties and persons or entities are collectively referred to as "Third

Parties."

You agree as

follows:

That you will cooperate with us in protecting our legal and equitable rights to subrogation and

reimbursement, including:

Providing any relevant information requested by us.

Signing and/or delivering such documents as we or our agents reasonably request to secure the

subrogation and reimbursement claim.

Responding to requests for information about any accident or injuries.

Making court appearances.

COC.I.11.WI

53

Obtaining our consent or our agents’ consent before releasing any party from liability or payment of

medical expenses.

That failure to cooperate in this manner shall be deemed a breach of contract, and may result in the

termination of health benefits or the instigation of legal action against you.

That we have the authority and discretion to resolve all disputes regarding the interpretation of the

language

stated

herein.

That no court costs or attorneys’ fees may be deducted from our recovery without our express written

consent; any so-called "Fund Doctrine" or "Common Fund Doctrine" or "Attorney’s Fund Doctrine" shall not

defeat this right, and we are not required to participate in or pay court costs or attorneys’ fees to the attorney

hired by you to pursue your damage/personal injury claim.

That after you have been fully compensated or made whole, we may collect from you the proceeds of any full

or partial recovery that you or your legal representative obtain, whether in the form of a settlement (either

before or after any determination of liability) or judgment, with such proceeds available for collection to

include any and all amounts earmarked as non-economic damage settlement or judgment.

That benefits paid by us may also be considered to be benefits

advanced.

That you agree that if you receive any payment from any potentially responsible party as a result of an injury

or illness, whether by settlement (either before or after any determination of liability), or judgment, you will

serve as a constructive trustee over the funds, and failure to hold such funds in trust will be deemed as a

breach of your duties hereunder.

That you or an authorized agent, such as your attorney, must hold any funds due and owing us, as stated

herein, separately and alone, and failure to hold funds as such will be deemed as a breach of contract, and

may result in the termination of health benefits or the instigation of legal action against you.

That we may set off from any future benefits otherwise provided by us the value of benefits paid or

advanced

under

this section to the extent not recovered by

us.

That you will not accept any settlement that does not fully compensate or reimburse us without our

written

approval, nor will you do anything to prejudice our rights under this

provision.

That you will assign to us all rights of recovery against Third Parties, to the extent of the reasonable value of

services and Benefits we provided, plus reasonable costs of collection.

That our rights will be considered as the first priority claim against Third Parties, including tortfeasors

from

whom you are seeking recovery, to be paid before any other of your claims are

paid.

That we may, at our option, take necessary and appropriate action to preserve our rights under

these

subrogation provisions, including filing suit in your name, which does not obligate us in any way to pay

you

part of any recovery we might

obtain.

That we shall not be obligated in any way to pursue this right independently or on your behalf.

That in the case of your wrongful death, the provisions of this section will apply to your estate, the

personal

representative of your estate and your heirs or

beneficiaries.

That the provisions of this section apply to the parents, guardian, or other representat ive of a

Dependent

child

who incurs a Sickness or Injury caused by a Third Party. If a parent or guardian may bring a claim

for

damages arising out of a minor’s Injury, the terms of this subrogation and reimbursement clause shall

apply

to that

claim.

Refund of Overpayments

If we pay Benefits for expenses incurred on account of a Covered Person, that Covered Person, or any other

person or organization that was paid, must make a refund to us if any of the following apply:

All or some of the expenses were not paid by the Covered Person or did not legally have to be paid by

the

Covered

Person.

All or some of the payment we made exceeded the Benefits under the

Policy.

All

or some of the payment was made in error.

The refund equals the amount we paid in excess of the amount we should have paid under the Policy. If the

refund is due from another person or organization, the Covered Person agrees to help us get the refund when

requested.

COC.I.11.WI

54

If the Covered Person, or any other person or organization that was paid, does not promptly refund the full

amount, we may reduce the amount of any future Benefits for the Covered Person that are payable under the

Policy. The reductions will equal the amount of the required refund. We may have other rights in addition to the

right to reduce future benefits.

Limitation of Action

You cannot bring any legal action against us to recover reimbursement until you have completed all the steps

in

the appeal process described in Section 6: Questions, Complaints and Appeals. After completing that process,

if

you want to bring a legal action against us you must do so within three years of the date we notified you of

our

final decision on your appeal or you lose any rights to bring such an action against

us.

Entire Policy

The Policy issued to the Enrolling Group, including this

Certificate,

the Schedule of Benefits, the Enrolling Group’s

application and any Riders and/or Amendments, constitutes the entire Policy.

COC.I.11.WI

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Section 9: Defined

Terms

Alternate Facility - a health care facility that is not a Hospital and that provides one or more of the following

services on an outpatient basis, as permitted by law:

Surgical services.

Emergency Health

Services.

Rehabilitative, laboratory, diagnostic or therapeutic services.

An Alternate Facility may also provide Mental Health Services or Substance Use Disorder Services on an

outpatient or inpatient basis.

Amendment - any attached written description of additional or alternative provisions to the Policy. Amendments

are effective only when signed by us. Amendments are subject to all conditions, limitations and exclusions of the

Policy, except for those that are specifically amended.

Annual Deductible - for Benefit plans that have an Annual Deductible, this is the amount of Eligible Expenses

you must pay for Covered Health Services per year before we will begin paying for Benefits. The amount that is

applied to the Annual Deductible is calculated on the basis of Eligible Expenses. The Annual Deductible does not

include any amount that exceeds Eligible Expenses. Refer to the Schedule of Benefits to determine whether or not

your Benefit plan is subject to payment of an Annual Deductible and for details about how the Annual Deductible

applies.

Autism Spectrum Disorders - a group of neurobiological disorders that includes Autistic Disorder, Rhett’s

Syndrome, Asperger’s Disorder, Childhood Disintegrated Disorder

and Pervasive Development Disorders Not

Otherwise Specified (PDDNOS).

Benefits - your right to payment for Covered Health Services that are available under the Policy. Your right

to

Benefits is subject to the terms, conditions, limitations and exclusions of the Policy, including this Certificate,

the

Schedule of Benefits and any attached Riders and/or

Amendments.

Coinsurance - the charge, stated as a percentage of Eligible Expenses, that you are required to pay for

certain

Covered Health

Services.

Congenital Anomaly - a physical developmental defect that is present at the time of birth, and that is

identified

within the first twelve months of

birth.

Copayment - the charge, stated as a set dollar amount, that you are required to pay for certain Covered

Health

Services.

Please note that for Covered Health Services, you are responsible for paying the lesser of the

following:

The applicable Copayment.

The Eligible

Expense.

Cosmetic Procedures - procedures or services that change or improve appearance without

significantly

improving physiological function, as determined by us.

Covered Health Service(s) - those health services, including services, supplies, or Pharmaceutical Products,

which we determine to be all of the following:

Medically

Necessary.

Described as a Covered Health Service in this

Certificate

under Section 1: Covered Health Services and in

the

Schedule of Benefits.

Not otherwise excluded in this

Certificate

under Section 2: Exclusions and Limitations.

Covered Person - either the Subscriber or an Enrolled Dependent, but this term applies only while the person is

enrolled under the Policy. References to "you" and "your" throughout this Certificate are references to a Covered

Person.

Custodial Care - services that are any of the following:

Non-health-related services, such as assistance in activities of daily living (examples include feeding,

dressing, bathing, transferring and ambulating).

COC.I.11.WI

56

Health-related services that are provided for the primary purpose of meeting the personal needs of the

patient or maintaining a level of function (even if the specific services are considered to be skilled services),

as opposed to improving that function to an extent that might allow for a more independent existence.

Services that do not require continued administration by trained medical personnel in order to be

delivered

safely and

effectively.

Dependent - the Subscriber’s legal spouse or a child of the Subscriber or the Subscriber’s spouse. The term

child

includes any of the

following:

A natural child.

A stepchild.

A legally adopted

child.

A child placed for adoption.

A child for whom legal guardianship has been awarded to the Subscriber or the Subscriber’s spouse.

A child of an Enrolled Dependent child (grandchild) until the Enrolled Dependent who is the parent turns

18.

To

be eligible for coverage under the Policy, a Dependent must reside within the United

States.

The definition of Dependent is subject to the following conditions and

limitations:

A Dependent includes any child listed above under 26 years of age.

A Dependent includes an unmarried child who is 26 years of age or older, but less than 27 years of age who

meets either of the following requirements:

The child is not eligible for coverage under a group health benefit plan offered by the child’s employer or

the child’s employer does not offer health insurance benefits to their employees.

The child is eligible for coverage under a group health benefit plan offered by the child’s employer, but

the amount of the child’s premium contribution is greater than the premium amount for his or her

coverage as an Enrolled Dependent child under the Subscriber’s plan.

A Dependent includes an unmarried dependent child age 26 or older who is or becomes disabled

and

dependent upon the

Subscriber.

A Dependent also includes an adult child who meets all of the following

requirements:

The child was under age 27 when called to federal active

duty.

The child was called to federal active duty in the national guard or in a reserve component of the U.S. armed

forces while the child was attending, on a full-time basis, an institution of higher education.

The child is a Full-time Student, regardless of

age.

The child is not

married.

The child is not eligible for coverage under a group health benefit plan offered by the child’s employer or the

child is eligible for coverage under a group health benefit plan offered by the child’s employer, but the

amount of the child’s premium contribution is greater than the premium amount for his or her coverage as a

dependent under the Subscriber’s

plan.

The child’s employer does not offer health insurance benefits to their employees.

The child must apply to an institution of higher education as a Full-time Student within twelve months

from

the

date the child has fulfilled his or her active duty

obligation.

When the child is called to active duty more than once within a four-year period of time, we will use

the

child’s age when first called to active duty for determining

eligibility.

The Subscriber must reimburse us for any Benefits that we pay for a child at a time when the child did not

satisfy

these

conditions.

A Dependent also includes a child for whom health care coverage is required through a Qualified Medical Child

Support Order

or other court or administrative order. The Enrolling Group is responsible for determining if

an

order meets the criteria of a

Qualified

Medical Child Support Order.

A Dependent does not include anyone who is also enrolled as a Subscriber. No one can be a Dependent of

more

than one

Subscriber.

COC.I.11.WI

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Designated Facility - a facility that has entered into an agreement with us, or with an organization contracting on

our behalf, to render Covered Health Services for the treatment of specified diseases or conditions. A Designated

Facility may or may not be located within your geographic area. The fact that a Hospital is a Network Hospital

does not mean that it is a Designated Facility.

Designated Network Benefits - for Benefit plans that have a Designated Network Benefit level, this is the

description of how Benefits are paid for Covered Health Services provided by a Physician or other provider that

we have identified as Designated Network providers. Refer to the Schedule of Benefits to determine whether or not

your Benefit plan offers Designated Network Benefits and for details about how Designated Network Benefits

apply.

Designated Physician - a Physician that we’ve identified through our designation programs as a Designated

provider. A Designated Physician may or may not be located within your geographic area. The fact that a

Physician is a Network Physician does not mean that he or she is a Designated Physician.

Durable Medical Equipment - medical equipment that is all of the following:

Can withstand repeated use.

Is not

disposable.

Is used to serve a medical purpose with respect to treatment of a Sickness, Injury or their symptoms.

Is generally not useful to a person in the absence of a Sickness, Injury or their symptoms.

Is appropriate for use, and is primarily used, within the

home.

Is

not implantable within the

body.

Eligible Expenses - for Covered Health Services, incurred while the Policy is in effect, Eligible Expenses

are

determined by us as stated below and as detailed in the Schedule of Benefits.

Eligible Expenses are determined solely in accordance with our reimbursement policy guidelines. We develop

our

reimbursement policy guidelines, in our discretion, following evaluation and validation of all provider billings

in

accordance with one or more of the following

methodologies:

As indicated in the most recent edition of the Current Procedural Terminology (CPT), a publication of the

American Medical

Association,

and/or the Centers for Medicare and Medicaid Services (CMS).

As reported by generally recognized professionals or

publications.

As

used for

Medicare.

As determined by medical staff and outside medical consultants pursuant to other appropriate source or

determination that we accept.

Eligible Person - an employee of the Enrolling Group or other person whose connection with the Enrolling Group

meets the eligibility requirements specified in both the application and the Policy. An Eligible Person must reside

within the United States.

Emergency - a serious medical condition or symptom resulting from Injury, Sickness or Mental Illness including

severe pain which would lead a prudent lay person with an average knowledge of health and medicine to

reasonably conclude that a lack of immediate medical attention will likely result in any of the

following:

Serious jeopardy to the person’s health or, with respect to a pregnant woman, serious jeopardy to the health

of the woman or her unborn child.

Serious impairment to the person’s bodily

functions.

Serious dysfunction of one or more of the person’s body organ or

parts.

Emergency Health Services - health care services and supplies necessary for the treatment of an

Emergency.

Enrolled Dependent - a Dependent who is properly enrolled under the

Policy.

Enrolling Group - the employer, or other defined or otherwise legally established group, to whom the Policy

is

issued.

Experimental or Investigational Service(s) - medical, surgical, diagnostic, psychiatric, mental health,

substance

use disorders or other health care services, technologies, supplies, treatments, procedures, drug

therapies,

medications or devices that, at the time we make a determination regarding coverage in a particular case,

are

determined to be any of the

following:

COC.I.11.WI

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Not approved by the U.S. Food and Drug

Administration

(FDA) to be lawfully marketed for the proposed use

and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing

Information

as appropriate for the proposed use.

Subject to review and approval by any institutional review board for the proposed use. (Devices which

are

FDA

approved under the Humanitarian Use Device exemption are not considered to be Experimental

or

Investigational.)

The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial set forth in

the FDA regulations, regardless of whether the trial is actually subject to FDA oversight.

Exceptions:

Clinical trials for which Benefits are available as described under Clinical Trials in Section 1: Covered Health

Services.

Life-Threatening Sickness or Condition. If you have a life-threatening Sickness or condition (one that is

likely

to

cause death within one year of the request for treatment) we may, in our discretion, consider an

otherwise

Experimental or Investigational Service to be a Covered Health Service for that Sickness or condition.

Prior

to such a consideration, we must first establish that there is sufficient evidence to conclude that,

albeit

unproven, the service has significant potential as an effective treatment for that Sickness or

condition.

Genetic Testing - examination of blood or other tissue for chromosomal and DNA abnormalit ies and

alterations,

or other expressions of gene abnormalities that may indicate an increased risk for developing a specific

disease

or

disorder.

Home Health Agency - a program or organization authorized by law to provide health care services in the

home.

Hospital - an institution that is operated as required by law and that meets both of the

following:

It is primarily engaged in providing health services, on an inpatient basis, for the acute care and treatment

of

injured or sick individuals. Care is provided through medical, diagnostic and surgical facilities, by or

under

the supervision of a staff of

Physicians.

It has 24-hour nursing services.

A Hospital is not primarily a place for rest, Custodial Care or care of the aged and is not a nursing home,

convalescent home or similar institution.

Initial Enrollment Period - the initial period of time during which Eligible Persons may enroll themselves and

their Dependents under the Policy.

Injury - bodily damage other than Sickness, including all related conditions and recurrent symptoms.

Inpatient Rehabilitation Facility - a long term acute rehabilitation center, a Hospital (or a special unit of a

Hospital designated as an Inpatient Rehabilitation Facility) that provides rehabilitation health services (including

physical therapy, occupational therapy and/or speech therapy) on an inpatient basis, as authorized by law.

Inpatient Stay - an uninterrupted confinement that follows formal admission to a Hospital, Skilled Nursing Facility

or Inpatient Rehabilitation Facility.

Intensive Outpatient Treatment - a structured outpatient mental health or substance use disorder

treatment

program that may be free-standing or Hospital-based and provides services for at least three hours per day,

two

or more days per

week.

Intermittent Care - skilled nursing care that is provided or needed

either:

Fewer than seven days each week.

Fewer than eight hours each day for periods of 21 days or

less.

Exceptions may be made in exceptional circumstances when the need for additional care is finite

and

predictable.

Manipulative Treatment - the therapeutic application of chiropractic and/or osteopathic manipulative

treatment

with or without ancillary physiologic treatment and/or rehabilitative methods rendered to restore/improve motion,

reduce pain and improve function in the management of an identifiable neuromusculoskeletal condition.

Medically Necessary - health care services provided for the purpose of preventing, evaluating, diagnosing or

COC.I.11.WI

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treating a Sickness, Injury, Mental Illness, substance use disorder, condition, disease or its symptoms, that are all

of the following as determined by us or our designee, within our sole discretion.

In accordance with Generally Accepted Standards of Medical Practice.

Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for

your

Sickness, Injury, Mental Illness, substance use disorder, disease or its

symptoms.

Not mainly for your convenience or that of your doctor or other health care provider.

Not more costly than an alternative drug, service(s) or supply that is at least as likely to produce equivalent

therapeutic or diagnostic results as to the diagnosis or treatment of your Sickness, Injury, disease or

symptoms.

Generally Accepted Standards of Medical Practice are standards that are based on credible scientific evidence

published in peer-reviewed medical literature generally recognized by the relevant medical community, relying

primarily on controlled clinical trials, or, if not available, observational studies from more than one institution that

suggest a causal relationship between the service or treatment and health outcomes.

If no credible scientific evidence is available, then standards that are based on Physician specialty society

recommendations or professional standards of care may be considered. We reserve the right to consult expert

opinion in determining whether health care services are Medically Necessary. The decision to apply Physician

specialty society recommendations, the choice of expert and the determination of when to use any such expert

opinion, shall be within our sole discretion.

We develop and maintain clinical policies that describe the Generally Accepted Standards of Medical Practice

scientific evidence, prevailing medical standards and clinical guidelines supporting our

determinati

ons regarding

specific services. These clinical policies (as developed by us and revised from time to time), are available to

Covered Persons on

www.myuhc.com or by calling Customer Care at the telephone number on your ID card, and

to Physicians and other health care professionals on UnitedHealthcareOnline.

Medicare - Parts A, B, C and D of the insurance program established by Title XVIII, United States Social Security

Act, as amended by 42 U.S.C. Sections 1394, et seq. and as later amended.

Mental Health Services - Covered Health Services for the diagnosis and treatment of Mental Illnesses. The fact

that a condition is listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association

does not mean that treatment for the condition is a Covered Health Service.

Mental Health/Substance Use Disorder Designee - the organization or individual, designated by us, that

provides or arranges Mental Health Services and Substance Use Disorder Services for which Benefits are

available under the Policy.

Mental Illness - those mental health or psychiatric diagnostic categories that are listed in the current Diagnostic

and Statistical Manual of the American Psychiatric Association, unless those services are specifically excluded

under the Policy.

Network - when used to describe a provider of health care services, this means a provider that has a participation

agreement in effect (either directly or indirectly) with us or with our affiliate to participate in our Network; however,

this does not include those providers who have agreed to discount their charges for Covered Health Services by

way of their participation in the Shared Savings Program. Our affiliates are those entities affiliated with us

through

common ownership or control with us or with our ultimate corporate parent, including direct and

indirect

subsidiaries.

A provider may enter into an agreement to provide only certain Covered Health Services, but not all

Covered

Health Services, or to be a Network provider for only some of our products. In this case, the provider will be

a

Network provider for the Covered Health Services and products included in the participation agreement, and

a

non-Network provider for other Covered Health Services and products. The participation status of providers

will

change from time to

time.

Network Benefits - for Benefit plans that have a Network Benefit level, this is the description of how Benefits

are

paid for Covered Health Services provided by Network providers. Refer to the Schedule of Benefits to

determine

whether or not your Benefit plan offers Network Benefits and for details about how Network Benefits

apply.

New Pharmaceutical Product - a Pharmaceutical Product or new dosage form of a previously

approved

Pharmaceutical Product, for the period of time starting on the date the Pharmaceutical Product or new

dosage

form is approved by the U.S. Food and Drug

Administration

(FDA) and ending on the earlier of the following

dates:

COC.I.11.WI

60

The date it is assigned to a tier by our Pharmaceutical Product List Management Committee.

December 31st of the following calendar

year.

Non-Network Benefits - for Benefit plans that have a Non-Network Benefit level, this is the description of

how

Benefits are paid for Covered Health Services provided by non-Network providers. Refer to the Schedule of

Benefits

to determine whether or not your Benefit plan offers Non-Network Benefits and for details about

how

Non-Network Benefits

apply.

Open Enrollment Period - a period of time that follows the Initial Enrollment Period during which Eligible

Persons

may enroll themselves and Dependents under the Policy. The Enrolling Group determines the period of time

that

is the Open Enrollment

Period.

Out-of-Pocket Maximum - for Benefit plans that have an Out-of-Pocket Maximum, this is the maximum

amount

you pay every year. Refer to the Schedule of Benefits to determine whether or not your Benefit plan is subject

to

an Out-of-Pocket Maximum and for details about how the Out-of-Pocket Maximum

applies.

Partial Hospitalization/Day Treatment - a structured ambulatory program that may be a free-standing

or

Hospital-based program and that provides services for at least 20 hours per

week.

Pharmaceutical Product(s) - U.S. Food and Drug Administration (FDA)-approved prescription

pharmaceutical

products administered in connection with a Covered Health Service by a Physician or other health care

provider

within the scope of the provider’s license, and not otherwise excluded under the

Policy.

Pharmaceutical Product List - a list that categorizes into tiers medications, products or devices that have

been

approved by the U.S. Food and Drug Administration (FDA). This list is subject to our periodic review

and

modification (generally quarterly, but no more than six times per calendar year). You may determine to which

tier

a particular Pharmaceutical Product has been assigned through the Internet at www.myuhc.com or by

calling

Customer Care at the telephone number on your ID

card.

Pharmaceutical Product List Management Committee - the committee that we designate for, among

other

responsibilities, classifying Pharmaceutical Products into specific

tiers.

Physician - any Doctor of Medicine or Doctor of Osteopathy who is properly licensed and qualified by

law.

Please Note: Any podiatrist, dentist, psychologist, chiropractor, optometrist, clinical social worker, marriage

and

family therapist, nurse practitioner, professional counselor or other provider who acts within the scope of his

or

her license will be considered on the same basis as a Physician. The fact that we describe a provider as

a

Physician does not mean that Benefits for services from that provider are available to you under the

Policy.

Policy - the entire agreement issued to the Enrolling Group that includes all of the

following:

The Group Policy.

This Certificate.

The Schedule of Benefits.

The Enrolling Group’s

application.

Riders.

Amendments.

These documents make up the entire agreement that is issued to the Enrolling Group.

Policy Charge - the sum of the Premiums for all Subscribers and Enrolled Dependents enrolled under the Policy.

Pregnancy - includes all of the following:

Prenatal

care.

Postnatal

care.

Childbirth.

Any complications associated with

Pregnancy.

Premium - the periodic fee required for each Subscriber and each Enrolled Dependent, in accordance with the

terms of the Policy.

Primary Physician - a Physician who has a majority of his or her practice in general pediatrics, internal

medicine, obstetrics/gynecology, family practice or general medicine.

COC.I.11.WI

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Private Duty Nursing - nursing care that is provided to a patient on a one-to-one basis by licensed nurses in an

inpatient or home setting when any of the following are true:

No skilled services are identified.

Skilled nursing resources are available in the

facility.

The skilled care can be provided by a Home Health Agency on a per visit basis for a specific purpose.

The service is provided to a Covered Person by an independent nurse who is hired directly by the Covered

Person or his/her family. This includes nursing services provided on an inpatient or home-care basis,

whether the service is skilled or non-skilled independent nursing.

Residential Treatment Facility - a facility which provides a program of effective Mental Health Services or

Substance Use Disorder Services treatment and which meets all of the following requirements:

It is established and operated in accordance with applicable state law for residential treatment

programs.

It provides a program of treatment under the active participation and direction of a Physician and approved

by the Mental Health/Substance Use Disorder Designee.

It has or maintains a written, specific and detailed treatment program requiring full-time residence and

full-time participation by the patient.

It provides at least the following basic services in a 24-hour per day, structured

milieu:

Room and

board.

Evaluation and

diagnosis.

Counseling.

Referral and orientation to specialized community

resources.

A Residential Treatment Facility that qualifies as a Hospital is considered a

Hospital.

Rider - any attached written description of additional Covered Health Services not described in this Certificate.

Covered Health Services provided by a Rider may be subject to payment of additional Premiums. Riders

are

effective only when signed by us and are subject to all conditions, limitations and exclusions of the Policy

except

for those that are specifically amended in the

Rider.

Semi-private Room - a room with two or more beds. When an Inpatient Stay in a Semi-private Room is

a

Covered Health Service, the difference in cost between a Semi-private Room and a private room is a Benefit

only

when a private room is necessary in terms of generally accepted medical practice, or when a Semi-private

Room

is not

available.

Service Area - the geographic area we serve and that has been approved by the appropriate regulatory

agency.

Contact us to determine the exact geographic area we serve. The Service Area may change from time to

time.

Shared Savings Program - the Shared Savings Program provides access to discounts from the

provider’s

charges when services are rendered by those non-Network providers that participate in that program. We will

use

the Shared Savings Program to pay claims when doing so will lower Eligible Expenses. We do not credential

the

Shared Savings Program providers and the Shared Savings Program providers are not Network providers.

Accordingly, in Benefit plans that have both Network and Non-Network levels of Benefits, Benefits for Covered

Health Services provided by Shared Savings Program providers will be paid at the Non-Network Benefit level

(except in situations when Benefits for Covered Health Services provided by non-Network providers are payable

at Network Benefit levels, as in the case of Emergency Health Services). When we use the Shared Savings

Program to pay a claim, patient responsibility is limited to Coinsurance calculated on the contracted rate paid to

the provider, in addition to any required deductible.

Sickness - physical illness, disease or Pregnancy. The term Sickness as used in this Certificate does not include

Mental Illness or substance use disorders, regardless of the cause or origin of the Mental Illness or substance use

disorder.

Skilled Nursing Facility - a Hospital or nursing facility that is licensed and operated as required by law.

Small Enrolling Group - an employer that had an average of at least 2 but not more than 50 employees on

business days during the preceding calendar year, or reasonably expects to have an average of at least 2 but not

more than 50 employees on business days during the current calendar year, if the employee was not in existence

during the preceding calendar year and that employs at least 2 employees on the first day of the plan year.

COC.I.11.WI

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Specialist Physician - a Physician who has a majority of his or her practice in areas other than general

pediatrics, internal medicine, obstetrics/gynecology, family practice or general medicine.

Subscriber - an Eligible Person who is properly enrolled under the Policy. The Subscriber is the person (who is

not a Dependent) on whose behalf the Policy is issued to the Enrolling Group.

Substance Use Disorder Services - Covered Health Services for the diagnosis and treatment of alcoholism and

substance use disorders that are listed in the current Diagnostic and

Statistical

Manual of the American Psychiatric

Association, unless those services are specifically excluded. The fact that a disorder is listed in the Diagnostic and

Statistical Manual of the American Psychiatric Association does not mean that treatment of the disorder is a

Covered Health Service.

Total Disability or Totally Disabled - a Subscriber’s inability to perform all of the substantial and material duties

of his or her regular employment or occupation; and a Dependent’s inability to perform the normal activities of a

person of like age and sex.

Transitional Care - Mental Health Services and Substance Use Disorder Services that are provided in a less

restrictive manner than inpatient Hospital services but more intensive than outpatient services. Services are

provided through transitional living facilities, group homes and supervised apartments that provide 24-hour

supervision that are either:

Sober living arrangements such as drug-free housing or alcohol/drug halfway houses. These are transitional,

supervised living arrangements that provide stable and safe housing, an alcohol/drug-free environment and

support for recovery. A sober living arrangement may be utilized as an adjunct to ambulatory treatment

when treatment doesn’t offer the intensity and structure needed to assist the Covered Person with recovery.

Supervised living arrangements which are residences such as transitional living facilities, group homes

and

supervised apartments that provide members with stable and safe housing and the opportunity to learn

how

to manage their activities of daily living. Supervised living arrangements may be utilized as an adjunct

to

treatment when treatment doesn’t offer the intensity and structure needed to assist the Covered Person

with

recovery.

Unproven Service(s) - services, including medications, that are determined not to be effective for treatment of

the

medical condition and/or not to have a beneficial effect on health outcomes due to insufficient and

inadequate

clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing

published

peer-reviewed medical

literature.

Well-conducted randomized controlled trials. (Two or more treatments are compared to each other, and

the

patient is not allowed to choose which treatment is

received.)

Well-conducted cohort studies from more than one institution. (Patients who receive study treatment are

compared to a group of patients who receive standard therapy. The comparison group must be nearly

identical to the study treatment group.)

We have a process by which we compile and review clinical evidence with respect to certain health services.

From time to time, we issue medical and drug policies that describe the clinical evidence available with respect to

specific health care services. These medical and drug policies are subject to change without prior notice. You can

view these policies at www.myuhc.com.

Please

note:

If you have a life-threatening Sickness or condition (one that is likely to cause death within one year of the

request for treatment) we may, in our discretion, consider an otherwise Unproven Service to be a Covered

Health Service for that Sickness or condition. Prior to such a consideration, we must first establish that there

is sufficient evidence to conclude that, albeit unproven, the service has significant potential as an effective

treatment for that Sickness or condition.

We may, in our discretion, consider an otherwise Unproven Service to be a Covered Health Service for

a

Covered Person with a Sickness or Injury that is not life-threatening. For that to occur, all of the

following

conditions must be

met:

If the service is one that requires review by the U.S. Food and Drug

Administration

(FDA), it must be

FDA-approved.

It must be performed by a Physician and in a facility with demonstrated experience and expertise.

COC.I.11.WI

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The Covered Person must consent to the procedure acknowledging that we do not believe that sufficient

clinical evidence has been published in peer-reviewed medical literature to conclude that the service is

safe and/or effective.

At least two studies from more than one institution must be available in published peer-reviewed medical

literature that would allow us to conclude that the service is promising but unproven.

The service must be available from a Network Physician and/or a Network facility.

The decision about whether such a service can be deemed a Covered Health Service is solely at our discretion.

Other apparently similar promising but unproven services may not qualify.

Urgent Care Center - a facility that provides Covered Health Services that are required to prevent serious

deterioration of your health, and that are required as a result of an unforeseen Sickness, Injury, or the onset of

acute or severe symptoms.

SBN.CHP.I.11.WI

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UnitedHealthcare Choice

Plus

UnitedHealthcare Insurance

Company

Accessing Benefits

Schedule of Benefits

You can choose to receive Network Benefits or Non-Network

Benefits.

Network Benefits apply to Covered Health Services that are provided by a Network Physician or other

Network

provider. Emergency Health Services are always paid as Network Benefits. For facility charges, these are

Benefits

for Covered Health Services that are billed by a Network facility and provided under the direction of either

a

Network or non-Network Physician or other provider. Network Benefits include Physician services provided in

a

Network facility by a Network or a non-Network Emergency room Physician, radiologist, anesthesiologist

or

pathologist.

Non-Network Benefits apply to Covered Health Services that are provided by a non-Network Physician or

other

non-Network provider, or Covered Health Services that are provided at a non-Network

facility.

Depending on the geographic area and the service you receive, you may have access through our

Shared

Savings Program to non-Network providers who have agreed to discount their charges for Covered

Health

Services. If you receive Covered Health Services from these providers, the Coinsurance will remain the same as

it

is when you receive Covered Health Services from non-Network providers who have not agreed to discount

their

charges; however, the total that you owe may be less when you receive Covered Health Services from

Shared

Savings Program providers than from other non-Network providers because the Eligible Expense may be a

lesser

amount.

You must show your identification card (ID card) every time you request health care services from a

Network

provider. If you do not show your ID card, Network providers have no way of knowing that you are enrolled

under

a UnitedHealthcare Policy. As a result, they may bill you for the entire cost of the services you

receive.

Additional information about the network of providers and how your Benefits may be affected appears at

the end of this Schedule of Benefits.

If there is a conflict between this Schedule of Benefits and any summaries provided to you by the Enrolling

Group,

this Schedule of Benefits will

control.

Prior Authorization

We require prior authorization for certain Covered Health Services. In general, Network providers are

responsible

for obtaining prior authorization before they provide these services to you. There are some Network

Benefits,

however, for which you are responsible for obtaining prior authorization. Services for which prior authorization

is

required are identified below and in the Schedule of Benefits table within each Covered Health Service

category.

We recommend that you confirm with us that all Covered Health Services listed below have been prior

authorized

as required. Before receiving these services from a Network provider, you may want to contact us to verify

that

the Hospital, Physician and other providers are Network providers and that they have obtained the required

prior

authorization. Network facilities and Network providers cannot bill you for services they fail to prior authorize

as

required. You can contact us by calling the telephone number for Customer Care on your ID

card.

When you choose to receive certain Covered Health Services from non-Network providers, you are

responsible for obtaining prior authorization before you receive these services. Note that your obligation to

obtain prior authorization is also applicable when a non-Network provider intends to admit you to a

Network facility or refers you to other Network providers. Once you have obtained the authorization, please

review it carefully so that you understand what services have been authorized and what providers are

authorized to deliver the services that are subject to the authorization.

SBN.CHP.I.11.WI

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2

To obtain prior authorization, call the telephone number for Customer Care on your ID card. This call starts

the utilization review process.

The utilization review process is a set of formal techniques designed to monitor the use of, or evaluate the clinical

necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or settings. Such

techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review,

case management, discharge planning, retrospective review or similar programs.

Covered Health Services which Require Prior Authorization

Please note that prior authorization timelines apply. Refer to the applicable Benefit description in the

Schedule of Benefits table to determine how far in advance you must obtain prior authorization.

Ambulance - non-emergent air and ground.

Autism Spectrum Disorder

Services.

Clinical trials.

Congenital heart disease surgery.

Dental/Anesthesia Services - Hospital or ambulatory surgery

services.

Dental services - accidental.

Diabetes equipment - insulin pumps over $1,000.

Durable Medical Equipment over $1,000 in cost (either retail purchase cost or cumulative retail rental cost

of

a

single

item).

Genetic Testing -

BRCA.

Home health care.

Hospice care -

inpatient.

Hospital inpatient care - all scheduled admissions and maternity stays exceeding 48 hours for normal

vaginal

delivery or 96 hours for a cesarean section

delivery.

Kidney disease treatment.

Mental Health Services - inpatient services (including Partial

Hospitalization/Day

Treatment and services at

a

Residential Treatment Facility); Intensive Outpatient Treatment programs; outpatient

electro-convulsive

treatment; psychological testing; extended outpatient treatment visits beyond 45 - 50 minutes in

duration,

with or without medication

management.

Reconstructive procedures, including breast reconstruction surgery following

mastectomy.

Rehabilitation services and Manipulative Treatment - Manipulative Treatment.

Skilled Nursing Facility and Inpatient Rehabilitation Facility

services.

Substance Use Disorder Services - inpatient services (including Partial

Hospitalization/Day

Treatment

and

services at a Residential Treatment Facility); Intensive Outpatient Treatment programs; psychologica l

testing;

extended outpatient treatment visits beyond 45 - 50 minutes in duration, with or without

medication

management.

Surgery - only for the following outpatient surgeries: diagnostic catheterization and electrophysiology

implant

and

sleep apnea

surgeries.

Temporomandibular joint disorder services.

Therapeutics - only for the following services: dialysis, intensity modulated radiation therapy, and

MR-guided

focused

ultrasound.

Transplants.

For all other services, when you choose to receive services from non-Network providers, we urge you to

confirm

with us that the services you plan to receive are Covered Health Services. That’s because in some

instances,

certain procedures may not be Medically Necessary or may not otherwise meet the definition of a Covered

Health

Service, and therefore are excluded. In other instances, the same procedure may meet the definition of

Covered

Health Services. By calling before you receive treatment, you can check to see if the service is subject

to

limitations or

exclusions.

SBN.CHP.I.11.WI

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If you request a coverage determination at the time prior authorization is provided, the determination will be

made based on the services you report you will be receiving. If the reported services differ from those actually

received, our final coverage determination will be modified to account for those differences, and we will only pay

Benefits based on the services actually delivered to you.

If you choose to receive a service that has been determined not to be a Medically Necessary Covered Health

Service, you will be responsible for paying all charges and no Benefits will be paid.

Care Management

When you seek prior authorization as required, we will work with you to implement the care management

process

and to provide you with information about additional services that are available to you, such as

disease

management programs, health education, and patient

advocacy.

Special Note Regarding Medicare

If you are enrolled in Medicare on a primary basis (Medicare pays before we pay Benefits under the Policy), the

prior authorization requirements do not apply to you. Since Medicare is the primary payer, we will pay as

secondary payer as described in Section 7: Coordination of Benefits. You are not required to obtain authorization

before receiving Covered Health Services.

SBN.CHP.I.11.WI

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Benefits

Annual Deductibles are calculated on a calendar year

basis.

Out-of-Pocket Maximums are calculated on a calendar year

basis.

When Benefit limits apply, the limit stated refers to any combination of Network Benefits and

Non-Network

Benefits unless otherwise specifically

stated.

Benefit limits are calculated on a calendar year basis unless otherwise specifically

stated.

Payment Term And Description

Amounts

Annual Deductible

The amount of Eligible Expenses you pay for Covered

Health

Services per year before you are eligible to receive

Benefits.

Amounts paid toward the Annual Deductible for Covered

Health

Services that are subject to a visit or day limit will also

be

calculated against that maximum Benefit limit. As a result,

the

limited Benefit will be reduced by the number of days/visits

used

toward meeting the Annual

Deductible.

When a Covered Person was previously covered under a

group

policy that was replaced by the group Policy, any amount

already

applied to that annual deductible provision of the prior policy

will

apply to the Annual Deductible provision under the

Policy.

The amount that is applied to the Annual Deductible is

calculated

on the basis of Eligible Expenses. The Annual Deductible does

not

include any amount that exceeds Eligible Expenses. Details

about

the way in which Eligible Expenses are determined appear at

the

end of the Schedule of Benefits

table.

Network

$1,000 per Covered Person, not to

exceed

$3,000 for all Covered Persons in a

family.

Non-Network

$2,000 per Covered Person, not to

exceed

$6,000 for all Covered Persons in a

family.

Out-of-Pocket Maximum

The maximum you pay per year for the Annual Deductible

or

Coinsurance. Once you reach the Out-of-Pocket

Maximum,

Benefits are payable at 100% of Eligible Expenses during the

rest

of that year.

Copayments and Coinsurance for some Covered Health Services

will never apply to the Out-of-Pocket Maximum and those Benefits

will never be payable at 100% even when the Out-of-Pocket

Maximum is reached. Details about the way in which Eligible

Expenses are determined appear at the end of the Schedule of

Benefits table.

The Out-of-Pocket Maximum does not include any of the following

and, once the Out-of-Pocket Maximum has been reached, you still

will be required to pay the following:

Any charges for non-Covered Health Services.

The amount Benefits are reduced if you do not obtain prior

authorization as required.

Network

$3,500 per Covered Person, not to

exceed

$7,000 for all Covered Persons in a

family.

The Out-of-Pocket Maximum includes the

Annual Deductible.

Non-Network

$7,000 per Covered Person, not to exceed

$14,000 for all Covered Persons in a family.

The Out-of-Pocket Maximum includes the

Annual Deductible.

SBN.CHP.I.11.WI

Rev.3

5

Payment Term And Description

Amounts

Charges that exceed Eligible Expenses.

Copayments or Coinsurance for any Covered Health Service

identified in the Schedule of Benefits table that does not apply

to the Out-of-Pocket Maximum.

Copayments or Coinsurance for Covered Health

Services

provided under the

Outpatient Prescription

Drug Rider.

Copayment

Copayment is the amount you pay (calculated as a set dollar amount) each time you receive certain

Covered

Health Services. When Copayments apply, the amount is listed on the following pages next to the description

for

each Covered Health

Service.

Please note that for Covered Health Services, you are responsible for paying the lesser

of:

The applicable

Copayment.

The Eligible

Expense.

Details about the way in which Eligible Expenses are determined appear at the end of the Schedule of Benefits

table.

Coinsurance

Coinsurance is the amount you pay (calculated as a percentage of Eligible Expenses) each time you

receive

certain Covered Health

Services.

Details about the way in which Eligible Expenses are determined appear at the end of the Schedule of Benefits

table.

SBN.CHP.I.11.WI

Rev.3

6

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

1. Ambulance Services

Prior Authorization Requirement

In most cases, we will initiate and direct non-Emergency ambulance transportation. If you are

requesting

non-

Emergency ambulance services, you must obtain authorization as soon as possible prior to transport.

If

you

fail to obtain prior authorization as required, you will be responsible for paying all charges and no

Benefits

will

be

paid.

Emergency Ambulance

Network

Ground

Ambulance:

80%

Yes

Air Ambulance:

80%

Yes

Non-Network

Same

as

Network

Same

as

Network

Same

as

Network

Non-Emergency Ambulance

Ground or air ambulance, as we

determine

appropriate.

Network

Ground

Ambulance:

80%

Yes

Air Ambulance:

80%

Yes

SBN.CHP.I.11.WI

Rev.3

7

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

Non-Network

Same as

Network

Same as

Network

Same as

Network

2. Clinical Trials

Prior Authorization Requirement

You must obtain prior authorization as soon as the possibility of participation in a clinical trial arises. If you

fail

to obtain prior authorization as required, you will be responsible for paying all charges and no Benefits will

be

paid.

Depending upon the Covered Health Service,

Benefit

limits are the same as those stated under the

specific

Benefit category in this Schedule of Benefits.

Network

Depending upon where the Covered Health Service

is

provided, Benefits will be the same as those

stated

under each Covered Health Service category in

this

Schedule of Benefits.

Benefits are available when the Covered

Health

Services are provided by either Network

or

non-Network providers, however the

non-Network

provider must agree to accept the Network level

of

reimbursement by signing a network

provider

agreement specifically for the patient enrolling in the

trial. (Non-Network Benefits are not available if the

non-Network provider does not agree to accept the

Network level of reimbursement.)

Non-Network

Depending upon where the Covered Health Service

is

provided, Benefits will be the same as those

stated

under each Covered Health Service category in

this

Schedule of Benefits.

3. Congenital Heart Disease Surgeries

Prior Authorization Requirement

For Non-Network Benefits you must obtain prior authorization as soon as the possibility of a congenital

heart

disease (CHD) surgery arises. If you fail to obtain prior authorization as required, Benefits will be reduced

to

50% of Eligible

Expenses.

Network and Non-Network Benefits under this section

include only the inpatient facility charges for

the

congenital heart disease (CHD) surgery.

Depending

Network

80%

Yes

SBN.CHP.I.11.WI

Rev.3

8

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

upon where the Covered Health Service is provided,

Benefits for diagnostic services, cardiac catheterization

and non-surgical management of CHD will be the same

as those stated under each Covered Health Service

category in this Schedule of Benefits.

Non-Network

60%

Yes

4. Dental Services - Accident Only

Prior Authorization Requirement

For Network and Non-Network Benefits you must obtain prior authorization five business days before

follow-up

(post-Emergency) treatment begins. (You do not have to obtain prior authorization before the initial

Emergency

treatment.) If you fail to obtain prior authorization as required, Benefits will be reduced to 50% of

Eligible

Expenses.

Limited to $3,000 per year. Benefits are further

limited

to a maximum of $900 per

tooth.

Network

80%

Yes

Non-Network

Same as

Network

Same as

Network

Same as

Network

5. Diabetes Services

Prior Authorization Requirement

For Non-Network Benefits you must obtain prior authorization before obtaining any Durable Medical

Equipment

for the management and treatment of diabetes that exceeds $1,000 in cost (either retail purchase cost

or

cumulative retail rental cost of a single item). If you fail to obtain prior authorization as required, you will

be

responsible for paying all charges and no Benefits will be

paid.

SBN.CHP.I.11.WI

Rev.3

9

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

Diabetes Self-Management and Training/Diabetic

Eye Examinations/Foot Care

Network

Depending upon where the Covered Health Service is

provided, Benefits for diabetes self-management and

training/diabetic eye examinations/foot care will be the

same as those stated under each Covered Health

Service category in this Schedule of Benefits.

Non-Network

Depending upon where the Covered Health Service

is

provided, Benefits for diabetes self-management

and

training/diabetic eye examinations/foot care will be

the

same as those stated under each Covered

Health

Service category in this Schedule of Benefits.

Diabetes Self-Management Items

Benefits for insulin pumps are limited to one pump

per

year.

Network

Depending upon where the Covered Health Service

is

provided, Benefits for diabetes self-management

items

will be the same as those stated under Durable

Medical Equipment

and in the

Outpatient

Prescription

Drug Rider.

Non-Network

Depending upon where the Covered Health Service

is

provided, Benefits for diabetes self-management

items

will be the same as those stated under Durable

Medical Equipment

and in the

Outpatient

Prescription

Drug Rider.

6. Durable Medical Equipment

Prior Authorization Requirement

For Non-Network Benefits you must obtain prior authorization before obtaining any Durable

Medical

Equipment that exceeds $1,000 in cost (either retail purchase cost or cumulative retail rental cost of a

single

item). If you fail to obtain prior authorization as required, you will be responsible for paying all charges and

no

Benefits will be

paid.

SBN.CHP.I.11.WI

Rev.3

10

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

Limited to $2,500 in Eligible Expenses per year.

Benefits are limited to a single purchase of a type of

DME (including repair/replacement) every three years.

This limit does not apply to wound vacuums.

To receive Network Benefits, you must purchase or

rent the Durable Medical Equipment from the vendor

we identify or purchase it directly from the prescribing

Network

Physician.

Cochlear implants are included under the

Durable

Medical Equipment benefit as required by

Wisconsin

insurance

law.

Network

80%

Yes

Non-Network

60%

Yes

7. Emergency Health Services - Outpatient

Note: If you are confined in a non-Network

Hospital

after you receive outpatient Emergency

Health

Services, you must notify us within one business day

or

on the same day of admission if reasonably

possible.

We may elect to transfer you to a Network Hospital

as

soon as it is medically appropriate to do so. If

you

choose to stay in the non-Network Hospital after the

date we decide a transfer is medically appropriate,

Network Benefits will not be provided. Non-Network

Benefits may be available if the continued stay is

determined to be a Covered Health Service.

Network

100% after

you

pay

a

Copayment

of

$250 per visit

.

If you are

admitted as an

inpatient to a

Network

Hospital

directly from

the Emergency

room, you will

not have to pay

this

Copayment.

The Benefits

for an Inpatient

Stay in a

Network

Hospital will

apply

instead.

No

SBN.CHP.I.11.WI

Rev.3

11

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

Non-Network

Same as

Network

Same as

Network

Same as

Network

8. Hearing Aids

Limited to $2,500 in Eligible Expenses per

year.

Benefits are limited to a single purchase

(including

repair/replacement)

per hearing impaired ear

every

three

years.

For Enrolled Dependent children under age

18,

Benefits are limited to one hearing aid per ear,

every

three years as required by Wisconsin insurance

law.

Hearing aids for Enrolled Dependent children are

not

subject to dollar

maximums.

Network

80%

Yes

Non-Network

60%

Yes

9. Home Health Care

Prior Authorization Requirement

For Non-Network Benefits you must obtain prior authorization five business days before receiving services

or

as soon as is reasonably possible. If you fail to obtain prior authorization as required, Benefits will be

reduced

to 50% of Eligible

Expenses.

Limited to 60 visits per year. One visit equals up to

four

hours of skilled care

services.

This visit limit does not include any service which

is

billed only for the administration of

intravenous

infusion.

Network

80%

Yes

SBN.CHP.I.11.WI

Rev.3

12

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

Non-Network

60%

Yes

10. Hospice Care

Prior Authorization Requirement

For Non-Network Benefits you must obtain prior authorization five business days before admission for

an

Inpatient Stay in a hospice facility or as soon as is reasonably possible. If you fail to obtain prior

authorization

as required, Benefits will be reduced to 50% of Eligible

Expenses.

In addition, for Non-Network Benefits, you must contact us within 24 hours of admission for an Inpatient

Stay

in a hospice

facility.

Network

80%

Yes

Non-Network

60%

Yes

11. Hospital - Inpatient Stay

Prior Authorization Requirement

For Non-Network Benefits for a scheduled admission, you must obtain prior authorization five business

days

before admission, or as soon as is reasonably possible for non-scheduled admissions (including

Emergency

admissions). If you fail to obtain prior authorization as required, Benefits will be reduced to 50% of

Eligible

Expenses.

In addition, for Non-Network Benefits you must contact us 24 hours before admission for

scheduled

admissions or as soon as is reasonably possible for non-scheduled admissions (including

Emergency

admissions).

Network

80%

Yes

SBN.CHP.I.11.WI

Rev.3

13

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

Non-Network

60% Yes Yes

12. Lab, X-Ray and Diagnostics - Outpatient

Lab Testing - Outpatient: Network

100% No

No

Non-Network

60% Yes

Yes

X-Ray and Other Diagnostic Testing - Outpatient: Network

100% No

No

Non-Network

60% Yes

Yes

13. Lab, X-Ray and Major Diagnostics - CT, PET,

MRI, MRA and Nuclear Medicine - Outpatient

Network

80% Yes

Yes

Non-Network

60% Yes

Yes

SBN.CHP.I.11.WI

Rev.3

14

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

14. Mental Health Services

Prior Authorization Requirement

For Non-Network Benefits for a scheduled admission for Mental Health Services (including an admission

for

Partial Hospitalization/Day Treatment and services at a Residential Treatment Facility) you must

obtain

authorization prior to the admission or as soon as is reasonably possible for non-scheduled

admissions

(including Emergency

admissions).

In addition, for Non-Network Benefits you must obtain prior authorization before the following services

are

received. Services requiring prior authorization: Intensive Outpatient Treatment programs;

outpatient

electro-convulsive treatment; psychological testing; extended outpatient treatment visits beyond 45 -

50

minutes in duration, with or without medication

management.

If you fail to obtain prior authorization as required, Benefits will be reduced to 50% of Eligible

Expenses.

Network

Inpatient

80%

Yes

Outpatient

100% after

you

pay

a

Copayment

of

$30 per

visit

No

Transitional

Care

100% after

you

pay

a

Copayment

of

$30 per

visit

No

Non-Network

Inpatient

60%

Yes

SBN.CHP.I.11.WI

Rev.3

15

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

Outpatient

60%

Yes

Transitional

Care

60%

Yes

15. Ostomy Supplies

Limited to $2,500 per

year.

Network

80%

Yes

Non-Network

60%

Yes

16. Pharmaceutical Products - Outpatient

Network

80%

Yes

Non-Network

60%

Yes

17. Physician Fees for Surgical and Medical

Services

Network

80%

Yes

SBN.CHP.I.11.WI

Rev.3

16

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

Non-Network

60%

Yes

18. Physician’s Office Services - Sickness and

Injury

Prior Authorization Requirement

For Non-Network Benefits you must obtain prior authorization as soon as is reasonably possible

before

Genetic Testing - BRCA is performed. If you fail to obtain prior authorization as required, Benefits will

be

reduced to 50% of Eligible

Expenses.

In addition to the office visit Copayment stated in

this

section, the

Copayments/Coinsurance

and

any

deductible for the following services apply when

the

Covered Health Service is performed in a

Physician’s

office:

Major diagnostic and nuclear medicine

described

under

Lab, X-Ray and Major

Diagnostics

- CT, PET,

MRI, MRA and Nuclear Medicine - Outpatient.

Outpatient Pharmaceutical Products

described

under

Pharmaceutical

Products - Outpatient.

Diagnostic and therapeutic scopic

procedures

described under Scopic Procedures - Outpatient

Diagnostic

and Therapeutic.

Outpatient surgery procedures described

under

Surgery - Outpatient.

Outpatient therapeutic procedures described under

Therapeutic Treatments

- Outpatient.

Network

100% after

you

pay

a

Copayment

of

$30 per visit

for

a

Primary

Physician

office visit

or

$60 per visit

for

a

Specialist

Physician

office

visit

No

Non-Network

60%

Yes

SBN.CHP.I.11.WI

Rev.3

17

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

19. Pregnancy - Maternity Services

Prior Authorization Requirement

For Non-Network Benefits you must obtain prior authorization as soon as reasonably possible if the

Inpatient

Stay for the mother and/or the newborn will be more than 48 hours for the mother and newborn child

following

a normal vaginal delivery, or more than 96 hours for the mother and newborn child following a

cesarean

section delivery. If you fail to obtain prior authorization as required, Benefits will be reduced to 50% of

Eligible

Expenses.

It is important that you notify us regarding your Pregnancy. Your notification will open the opportunity to

become enrolled in prenatal programs that are designed to achieve the best outcomes for you and your

baby.

Network

Benefits will be the same as those stated under

each

Covered Health Service category in this Schedule of

Benefits

except that an Annual Deductible will

not

apply for a newborn child whose length of stay in

the

Hospital is the same as the mother’s length of

stay.

For Covered Health Services provided in

the

Physician’s Office, a Copayment will apply only to

the

initial office

visit.

Non-Network

Benefits will be the same as those stated under

each

Covered Health Service category in this Schedule of

Benefits

except that an Annual Deductible will

not

apply for a newborn child whose length of stay in

the

Hospital is the same as the mother’s length of

stay.

20. Preventive Care Services

Physician office services

Network

100%

No

SBN.CHP.I.11.WI

Rev.3

18

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

Non-Network

60%

No Copayment

or Coinsurance

applies to

influenza

immunizations.

Yes

Lab, X-ray or other preventive tests

Network

100%

No

Non-Network

60%

Yes

21. Prosthetic Devices

Limited to $2,500 per year. Benefits are limited to

a

single purchase of each type of prosthetic device

every

three

years.

Network

80%

Yes

Once this limit is reached, Benefits continue to be

available for items required by the Women’s Health and

Cancer Rights Act of 1998.

Non-Network

60%

Yes

SBN.CHP.I.11.WI

Rev.3

19

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

22. Reconstructive Procedures

Prior Authorization Requirement

For Non-Network Benefits you must obtain prior authorization five business days before a

scheduled

reconstructive procedure is performed or, for non-scheduled procedures, within one business day or as

soon

as is reasonably possible. If you fail to obtain prior authorization as required, Benefits will be reduced to 50%

of

Eligible

Expenses.

In addition, for Non-Network Benefits you must contact us 24 hours before admission for scheduled

inpatient

admissions or as soon as is reasonably possible for non-scheduled inpatient admissions (including

Emergency

admissions).

Network

Depending upon where the Covered Health Service

is

provided, Benefits will be the same as those

stated

under each Covered Health Service category in

this

Schedule of Benefits.

Non-Network

Depending upon where the Covered Health Service

is

provided, Benefits will be the same as those

stated

under each Covered Health Service category in

this

Schedule of Benefits.

23. Rehabilitation Services - Outpatient Therapy and

Manipulative Treatment

Prior Authorization Requirement

For Non-Network Benefits you must obtain prior authorization five business days before receiving

Manipulative

Treatment, or as soon as is reasonably possible. If you fail to obtain prior authorization as required,

Benefits

will

be reduced to 50% of Eligible

Expenses.

Limited per year as follows:

20 visits of physical

therapy.

20 visits of occupational

therapy.

20

visits of speech

therapy.

Network

100% after you

pay a

Copayment of

$30 per visit

No

SBN.CHP.I.11.WI

Rev.3

20

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

20 visits of pulmonary rehabilitation therapy.

36 visits of cardiac rehabilitation therapy.

30 visits of post-cochlear implant aural

therapy.

20 visits of cognitive rehabilitation

therapy.

Visit

limits do not apply to Manipulative

Therapy.

Non-Network

60%

Yes

24. Scopic Procedures - Outpatient Diagnostic and

Therapeutic

Network

80%

Yes

Non-Network

60%

Yes

25. Skilled Nursing Facility/Inpatient Rehabilitation

Facility Services

Prior Authorization Requirement

For Non-Network Benefits for a scheduled admission, you must obtain prior authorization five business

days

before admission, or as soon as is reasonably possible for non-scheduled admissions. If you fail to obtain

prior

authorization as required, Benefits will be reduced to 50% of Eligible

Expenses.

In addition, for Non-Network Benefits you must contact us 24 hours before admission for

scheduled

admissions or as soon as is reasonably possible for non-scheduled admissions (including

Emergency

admissions).

SBN.CHP.I.11.WI

Rev.3

21

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

For Skilled Nursing Facility services, Benefits are

limited to 30 days per Inpatient Stay.

For Inpatient Rehabilitation Facility services, Benefits

are limited to 60 days per year.

Network

80%

Yes

Non-Network

60%

Yes

26. Substance Use Disorder Services

Prior Authorization Requirement

For Non-Network Benefits for a scheduled admission for Substance Use Disorder Services (including

an

admission for Partial

Hospitalization/Day

Treatment and services at a Residential Treatment Facility) you

must

obtain authorization prior to the admission or as soon as is reasonably possible for non-scheduled

admissions

(including Emergency

admissions).

In addition, for Non-Network Benefits you must obtain prior authorization before the following services

are

received. Services requiring prior authorization: Intensive Outpatient Treatment programs; psychologic

al

testing; extended outpatient treatment visits beyond 45 - 50 minutes in duration, with or without

medication

management.

If you fail to obtain prior authorization as required, Benefits will be reduced to 50% of Eligible

Expenses.

Network

Inpatient

80%

Yes

Outpatient

100% after you

pay a

Copayment of

$30 per visit

No

SBN.CHP.I.11.WI

Rev.3

22

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

Transitional

Care

100% after you

pay a

Copayment of

$30 per visit

No

Non-Network

Inpatient

60%

Yes

Outpatient

60%

Yes

Transitional

Care

60%

Yes

27. Surgery - Outpatient

Prior Authorization Requirement

For Non-Network Benefits for diagnostic catheterization and electrophysiology implant and sleep

apnea

surgery

you must obtain prior authorization five business days before scheduled services are received or,

for

non-scheduled services, within one business day or as soon as is reasonably possible. If you fail to obtain

prior

authorization as required, Benefits will be reduced to 50% of Eligible

Expenses.

Network

80%

Yes

SBN.CHP.I.11.WI

Rev.3

23

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

Non-Network

60%

Yes

28. Temporomandibular Joint Disorder Services

Prior Authorization Requirement

For Non-Network Benefits you must obtain prior authorization five business days before

temporomandibular

joint disorder services are performed during an Inpatient Stay in a Hospital. If you fail to obtain

prior

authorization as required, Benefits will be reduced to 50% of Eligible

Expenses.

In addition, for Non-Network Benefits you must contact us 24 hours before admission for scheduled

inpatient

admissions.

Benefits for diagnostic procedures and

non-surgical

treatment are limited to $1,250 per calendar

year.

Network

Depending upon where the Covered Health Service

is

provided, Benefits will be the same as those

stated

under each Covered Health Service category in

this

Schedule of Benefits.

Non-Network

Depending upon where the Covered Health Service

is

provided, Benefits will be the same as those

stated

under each Covered Health Service category in

this

Schedule of Benefits.

29. Therapeutic Treatments - Outpatient

Prior Authorization Requirement

For Non-Network Benefits you must obtain prior authorization for the following outpatient therapeutic

services

five business days before scheduled services are received or, for non-scheduled services, within one

business

day or as soon as is reasonably possible. Services that require prior authorization: dialysis,

intensity

modulated radiation therapy and MR-guided focused ultrasound. If you fail to obtain prior authorization

as

required, Benefits will be reduced to 50% of Eligible

Expenses.

Network

80%

Yes

SBN.CHP.I.11.WI

Rev.3

24

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

Non-Network

60%

Yes

30. Transplantation Services

Prior Authorization Requirement

For Network Benefits you must obtain prior authorization as soon as the possibility of a transplant arises

(and

before the time a pre-transplantation evaluation is performed at a transplant center). If you don’t obtain

prior

authorization and if, as a result, the services are not performed at a Designated Facility, Network Benefits

will

not be paid. Non-Network Benefits will

apply.

For Non-Network Benefits you must obtain prior authorization as soon as the possibility of a transplant

arises

(and before the time a pre-transplantation evaluation is performed at a transplant center). If you fail to

obtain

prior authorization as required, Benefits will be reduced to 50% of Eligible

Expenses.

In addition, for Non-Network Benefits you must contact us 24 hours before admission for

scheduled

admissions or as soon as is reasonably possible for non-scheduled admissions (including

Emergency

admissions).

For Network Benefits, transplantation services must

be

received at a Designated Facility. We do not

require

that cornea transplants be performed at a

Designated

Facility in order for you to receive Network

Benefits.

Network

Depending upon where the Covered Health Service

is

provided, Benefits will be the same as those

stated

under each Covered Health Service category in

this

Schedule of Benefits.

Non-Network Benefits are limited to $30,000 per

transplant.

Non-Network

Depending upon where the Covered Health Service is

provided, Benefits will be the same as those stated

under each Covered Health Service category in this

Schedule of Benefits.

31. Urgent Care Center Services

In addition to the Copayment stated in this section, the

Copayments/Coinsurance and any deductible for the

following services apply when the Covered Health

Service is performed at an Urgent Care Center:

Major diagnostic and nuclear medicine described

Network

100% after you

pay a

Copayment

of

$100 per

visit

No

SBN.CHP.I.11.WI

Rev.3

25

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

under Lab, X-Ray and Major

Diagnostics

- CT, PET,

MRI, MRA and Nuclear Medicine - Outpatient.

Outpatient Pharmaceutical Products described

under

Pharmaceutical

Products - Outpatient.

Diagnostic and therapeutic scopic procedures

described under Scopic Procedures - Outpatient

Diagnostic

and Therapeutic.

Outpatient surgery procedures described

under

Surgery - Outpatient.

Outpatient therapeutic procedures described

under

Therapeutic Treatments

- Outpatient.

Non-Network

60%

Yes

32. Vision Examinations

Limited to 1 exam every 2 years.

Network

100% after you

pay a

Copayment of

$30 per

visit

No

Non-Network

60%

Yes

Additional Benefits Required By Wisconsin Law

33. Autism Spectrum Disorder Services

Prior Authorization Requirement

If you fail to obtain prior authorization as required, Benefits will be reduced to 50% of Eligible

Expenses.

SBN.CHP.I.11.WI

Rev.3

26

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

Network

Depending upon where the Covered Health Service is

provided, Benefits will be the same as those stated

under each Covered Health Service category in the

Schedule of Benefits.

Non-Network

Depending upon where the Covered Health Service

is

provided, Benefits will be the same as those

stated

under each Covered Health Service category in

the

Schedule of Benefits.

34. Dental/Anesthesia Services - Hospital

Ambulatory Surgery Center

Prior Authorization Requirement

Depending upon where the Covered Health Service is provided, any applicable authorization requirements

will

be the same as those stated under each Covered Health Service category in this Schedule of

Benefits.

Network

Depending upon where the Covered Health Service

is

provided, Benefits will be the same as those

stated

under each Covered Health Service category in

this

Schedule of Benefits.

Non-Network

Depending upon where the Covered Health Service

is

provided, Benefits will be the same as those

stated

under each Covered Health Service category in

this

Schedule of Benefits.

35. Kidney Disease Treatment

Prior Authorization Requirement

Depending upon where the Covered Health Service is provided, any applicable authorization requirements

will

be the same as those stated under each Covered Health Service category in this Schedule of

Benefits.

SBN.CHP.I.11.WI

Rev.3

27

When Benefit limits apply, the limit refers to any combination of Network Benefits and Non-Network

Benefits unless otherwise specifically stated.

Covered Health Service

Benefit (The

Amount We

Pay, based on

Eligible

Expenses)

Apply to the

Out-of-Pocket

Maximum?

Must You Meet

Annual

Deductible?

Network

Depending upon where the Covered Health Service is

provided, Benefits will be the same as those stated

under each Covered Health Service category in this

Schedule of Benefits.

Non-Network

Depending upon where the Covered Health Service

is

provided, Benefits will be the same as those

stated

under each Covered Health Service category in

this

Schedule of Benefits.

Eligible Expenses

Eligible Expenses are the amount we determine that we will pay for Benefits. For Network Benefits, you are

not

responsible for any difference between Eligible Expenses and the amount the provider bills. For

Non-Network

Benefits, you are responsible for paying, directly to the non-Network provider, any difference between the

amount

the provider bills you and the amount we will pay for Eligible Expenses. Eligible Expenses are determined

solely

in accordance with our reimbursement policy guidelines, as described in the Certificate.

For Network Benefits, Eligible Expenses are based on the

following:

When Covered Health Services are received from a Network provider, Eligible Expenses are our

contracted

fee(s)

with that

provider.

When Covered Health Services are received from a non-Network provider as a result of an Emergency or as

otherwise arranged by us, Eligible Expenses are billed charges unless a lower amount is negotiated or

authorized by state law.

For Non-Network Benefits, Eligible Expenses are based on either of the

following:

When Covered Health Services are received from a non-Network provider, Eligible Expenses are determined,

based on:

Negotiated rates agreed to by the non-Network provider and either us or one of our vendors, affiliates or

subcontractors, at our discretion.

If rates have not been negotiated, then one of the following amounts:

Eligible Expenses are determined based on 110% of the published rates allowed by the Centers for

Medicare and Medicaid Services (CMS) for Medicare for the same or similar service within the

geographic market.

When a rate is not published by CMS for the service, we use an available gap methodology

to

determine a rate for the service as

follows:

o For services other than Pharmaceutical Products, we use a gap methodology that uses

a

relative value scale, which is usually based on the difficulty, time, work, risk and resources

of

the service. The relative value scale currently used is created by

Ingenix,

Inc. If the Ingenix,

SBN.CHP.I.11.WI

Rev.3

28

Inc. relative value scale becomes no longer available, a comparable scale will be used. We

and

Ingenix,

Inc. are related companies through common ownership by

UnitedHealth

Group.

o For Pharmaceutical Products, we use gap methodologies that are similar to the pricing

methodology used by CMS, and produce fees based on published acquisition costs or

average wholesale price for the pharmaceuticals. These methodologies are currently created

by RJ Health Systems, Thomson Reuters (published in its Red Book), or UnitedHealthcare

based on an internally developed pharmaceutical pricing resource.

When a rate is not published by CMS for the service and a gap methodology does not apply to the

service, or the provider does not submit sufficient information on the claim to pay it under CMS

published rates or a gap methodology, the Eligible Expense is based on 50% of the provider’s

billed charge, except that certain Eligible Expenses for Mental Health Services and Substance Use

Disorder Services are based on 80% of the billed charge.

For Mental Health Services and Substance Use Disorder Services the Eligible Expense will

be

reduced

by 25% for Covered Health Services provided by a psychologist and by 35% for

Covered

Health Services provided by a masters level

counselor.

We update the CMS published rate data on a regular basis when updated data from CMS

becomes

available. These updates are typically implemented within 30 to 90 days after CMS updates its

data.

When Covered Health Services are received from a Network provider, Eligible Expenses are our contracted

fee(s) with that

provider.

Provider Network

We arrange for health care providers to participate in a Network. Network providers are

independent

practitioners. They are not our employees. It is your responsibility to select your

provider.

Our credentialing process confirms public information about the providers’ licenses and other credentials,

but

does not assure the quality of the services

provided.

Before obtaining services you should always verify the Network status of a provider. A provider’s status

may

change. You can verify the provider’s status by calling Customer Care. A directory of providers is available

online

at www.myuhc.com or by calling Customer Care at the telephone number on your ID card to request a

copy.

It is possible that you might not be able to obtain services from a particular Network provider. The network

of

providers is subject to change. Or you might find that a particular Network provider may not be accepting

new

patients. If a provider leaves the Network or is otherwise not available to you, you must choose another

Network

provider to get Network

Benefits.

If you are currently undergoing a course of treatment utilizing a non-Network Physician or health care facility,

you

may be eligible to receive transition of care Benefits. This transition period is available for specific

medical

services and for limited periods of time. If you have questions regarding this transition of care

reimbursement

policy or would like help determining whether you are eligible for transition of care Benefits, please

contact

Customer Care at the telephone number on your ID

card.

Do not assume that a Network provider’s agreement includes all Covered Health Services. Some Network

providers contract with us to provide only certain Covered Health Services, but not all Covered Health Services.

Some Network providers choose to be a Network provider for only some of our products. Refer to your provider

directory or contact us for assistance.

Designated Facilities and Other Providers

If you have a medical condition that we believe needs special services, we may direct you to a Designated

Facility

or Designated Physician chosen by us. If you require certain complex Covered Health Services for

which

expertise is limited, we may direct you to a Network facility or provider that is outside your local geographic

area.

If you are required to travel to obtain such Covered Health Services from a Designated Facility or

Designated

Physician, we may reimburse certain travel expenses at our

discretion.

In both cases, Network Benefits will only be paid if your Covered Health Services for that condition are

provided

by or arranged by the Designated Facility, Designated Physician or other provider chosen by

us.

You or your Network Physician must notify us of special service needs (such as transplants, or cancer

treatment)

SBN.CHP.I.11.WI

Rev.3

29

that might warrant referral to a Designated Facility or Designated Physician. If you do not notify us in advance,

and if you receive services from a non-Network facility (regardless of whether it is a Designated Facility) or other

non-Network provider, Network Benefits will not be paid. Non-Network Benefits may be available if the special

needs services you receive are Covered Health Services for which Benefits are provided under the Policy.

Health Services from Non-Network Providers Paid as Network Benefits

If specific Covered Health Services are not available from a Network provider, you may be eligible for

Network

Benefits when Covered Health Services are received from non-Network providers. In this situation, your

Network

Physician will notify us and, if we confirm that care is not available from a Network provider, we will work with

you

and your Network Physician to coordinate care through a non-Network

provider.

Limitations on Selection of Providers

If we determine that you are using health care services in a harmful or abusive manner, or with harmful

frequency, your selection of Network providers may be limited. If this happens, we may require you to select a

single Network Physician to provide and coordinate all future Covered Health Services.

If you don’t make a selection within 31 days of the date we notify you, we will select a single Network Physician

for you.

If you fail to use the selected Network Physician, Covered Health Services will be paid as Non-Network Benefits.

DEPENDENTCOV.AMD.I.11.WI

Dependent Coverage

Amendment

UnitedHealthcare Insurance

Company

As described in this Amendment, the Policy is modified to redefine Dependent.

Because this Amendment is part of a legal document (the group Policy), we want to give you information about

the document that will help you understand it. Certain capitalized words have special meanings. We have defined

these words in the

Certificate

of Coverage

(Certificate)

in Section 9: Defined Terms.

1. The definition of Dependent in the Certificate under Section 9: Defined Terms is replaced with the following:

Dependent - the Subscriber’s legal spouse or a child of the Subscriber or the Subscriber’s spouse. The term child

includes any of the following:

A natural child.

A

stepchild.

A legally adopted

child.

A child placed for adoption.

A child for whom legal guardianship has been awarded to the Subscriber or the Subscriber’s

spouse.

A child of an Enrolled Dependent child (grandchild) until the Enrolled Dependent who is the parent turns

18.

To

be eligible for coverage under the Policy, a Dependent must reside within the United

States.

The definition of Dependent is subject to the following conditions and

limitations:

A Dependent includes any child listed above under 26 years of age.

A Dependent includes an unmarried dependent child age 26 or older who is or becomes disabled

and

dependent upon the

Subscriber.

A Dependent also includes an adult child who meets all of the following

requirements:

The child is a Full-time Student, regardless of

age.

The child was called to federal active duty in the national guard or in a reserve component of the U.S. armed

forces while the child was attending, on a full-time basis, an institution of higher education.

The child was under age 27 when called to federal active

duty.

The child must apply to an institution of higher education as a Full-time Student within twelve months

from

the date the child has fulfilled his or her active duty

obligation.

When the child is called to active duty more than once within a four-year period of time, we will use

the

child’s age when first called to active duty for determining

eligibility.

The Subscriber must reimburse us for any Benefits that we pay for a child at a time when the child did not

satisfy

these

conditions.

A Dependent also includes a child for whom health care coverage is required through a Qualified Medical Child

Support Order

or other court or administrative order. The Enrolling Group is responsible for determining if

an

order meets the criteria of a

Qualified

Medical Child Support Order.

DEPENDENTCOV.AMD.I.11.WI

A Dependent does not include anyone who is also enrolled as a Subscriber. No one can be a Dependent of more

than one Subscriber.

UnitedHealthcare Insurance Company

President

CT14.AMD.I.WI.SB

1

Clinical Trials and Patient Protection and Affordable

Care

Act (PPACA) Related 2014 Provisions

Amendment

UnitedHealthcare Insurance

Company

As described in this Amendment, the Policy is modified as stated below. This Amendment is applicable to Policies

issued in the state of Wisconsin.

Because this Amendment reflects changes in requirements of Federal law, to the extent it may conflict with any

Amendment issued to you previously, the provisions of this Amendment will govern.

Any provision of this Amendment which is in conflict with the requirements of state or federal statutes or

regulations (of the jurisdiction in which the Amendment is delivered) is hereby amended to conform to the

minimum requirements of such statutes and regulations.

1. Clinical Trials

Benefits for routine patient care costs incurred by a Covered Person when participating in a qualifying clinical

trial

are required under the Patient Protection and Affordable Care Act (PPACA). The Benefit for Clinical Trials and

the

definition of Experimental or Investigational Service(s) in the

Certificate

are replaced as described

below:

Section 1: Covered Health

Services

Clinical

Trials in Section 1: Covered Health Services is replaced with the following:

2. Clinical Trials

Routine patient care costs incurred during participation in a qualifying clinical trial for the treatment of:

Cancer or other life-threatening disease or condition. For purposes of this benefit, a life-threatening

disease

or

condition is one from which the likelihood of death is probable unless the course of the disease

or

condition is

interrupted.

Cardiovascular disease (cardiac/stroke) which is not life threatening, for which, as we determine, a

clinical

trial

meets the qualifying clinical trial criteria stated

below.

Surgical musculoskeletal disorders of the spine, hip and knees, which are not life threatening, for which, as

we determine, a clinical trial meets the qualifying clinical trial criteria stated below.

Other diseases or disorders which are not life threatening for which, as we determine, a clinical trial

meets

the

qualifying clinical trial criteria stated

below.

Benefits include the reasonable and necessary items and services used to prevent, diagnose and treat

complications arising from participation in a qualifying clinical trial.

Benefits are available only when the Covered Person is clinically eligible for participation in the qualifying clinical

trial as defined by the researcher.

Routine patient care costs for qualifying clinical trials include:

Covered Health Services for which Benefits are typically provided absent a clinical

trial.

Covered Health Services required solely for the provision of the Investigational item or service, the

clinically

appropriate monitoring of the effects of the item or service, or the prevention of

complications.

Covered Health Services needed for reasonable and necessary care arising from the provision of an

Investigational item or service.

Routine costs for clinical trials do not include:

The Experimental or Investigational Service or item. The only exceptions to this are:

CT14.AMD.I.WI.SB

2

Certain Category B devices.

Certain promising interventions for patients with terminal illnesses.

Other items and services that meet specified criteria in accordance with our medical and drug policies.

Items and services provided solely to satisfy data collection and analysis needs and that are not used in the

direct clinical management of the patient.

A service that is clearly inconsistent with widely accepted and established standards of care for a

particular

diagnosis.

Items and services provided by the research sponsors free of charge for any person enrolled in the trial.

With respect to cancer or other life-threatening diseases or conditions, a qualifying clinical trial is a Phase I, Phase

II, Phase III, or Phase IV clinical trial that is conducted in relation to the prevention, detection or treatment of

cancer or other life-threatening disease or condition and which meets any of the following criteria in the bulleted

list below.

With respect to cardiovascular disease or musculoskeletal disorders of the spine, hip and knees and other

diseases or disorders which are not life-threatening, a qualifying clinical trial is a Phase I, Phase II, or Phase III

clinical trial that is conducted in relation to the detection or treatment of such non-life-threatening disease or

disorder and which meets any of the following criteria in the bulleted list below.

Federally funded trials. The study or investigation is approved or funded (which may include funding through

in-kind contributions) by one or more of the following:

National Institutes

of Health (NIH). (Includes

National

Cancer

Institute

(NCI).)

Centers for Disease Control and Prevention (CDC).

Agency for

Healthcare

Research and Quality (AHRQ).

Centers for Medicare and Medicaid Services (CMS).

A cooperative group or center of any of the entities described above or the

Department

of Defense

(DOD) or the Veterans

Administration

(VA).

A qualified non-governmental research entity identified in the guidelines issued by the

National

Institutes

of Health for center support grants.

The

Department

of Veterans Affairs, the

Department

of Defense or the

Department

of Energy as long as

the study or investigation has been reviewed and approved through a system of peer review that is

determined by the Secretary of Health and Human Services to meet both of the following criteria:

Comparable to the system of peer review of studies and investigations used by the National

Institutes

of Health.

Ensures unbiased review of the highest scientific standards by qualified individuals who have no

interest in the outcome of the review.

The study or investigation is conducted under an investigational new drug application reviewed by the U.S.

Food and Drug Administration.

The study or investigation is a drug trial that is exempt from having such an investigational new

drug

application.

The clinical trial must have a written protocol that describes a scientifically sound study and have

been

approved by all relevant institutional review boards (IRBs) before participants are enrolled in the trial.

We

may, at any time, request documentation about the

trial.

The subject or purpose of the trial must be the evaluation of an item or service that meets the definition of a

Covered Health Service and is not otherwise excluded under the Policy.

CT14.AMD.I.WI.SB

3

Section 9: Defined

Terms

The

definition

of Experimental or

Investigational

Service(s) in Section 9: Defined Terms is replaced with the following:

Experimental or Investigational Service(s) - medical, surgical, diagnostic, psychiatric, mental health, substance

use disorders or other health care services, technologies, supplies, treatments, procedures, drug therapies,

medications or devices that, at the time we make a determination regarding coverage in a particular case, are

determined to be any of the following:

Not approved by the U.S. Food and Drug

Administration

(FDA) to be lawfully marketed for the proposed use

and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing

Information

as appropriate for the proposed use.

Subject to review and approval by any institutional review board for the proposed use. (Devices which

are

FDA

approved under the Humanitarian Use Device exemption are not considered to be Experimental

or

Investigational.)

The subject of an ongoing clinical trial that meets the definition of a Phase I, II or III clinical trial set forth in

the FDA regulations, regardless of whether the trial is actually subject to FDA oversight.

Exceptions:

Clinical trials for which Benefits are available as described under Clinical Trials in Section 1: Covered Health

Services.

If you are not a participant in a qualifying clinical trial, as described under

Clinical

Trials in Section 1: Covered

Health Services,

and have a Sickness or condition that is likely to cause death within one year of the

request

for treatment we may, in our discretion, consider an otherwise Experimental or Investigational Service to

be

a Covered Health Service for that Sickness or condition. Prior to such a consideration, we must first

establish

that there is sufficient evidence to conclude that, albeit unproven, the service has significant potential as

an

effective treatment for that Sickness or

condition.

2. Additional Patient Protection and Affordable Care Act (PPACA) Related

2014 Provisions

Durable Medical Equipment

Benefits for Durable Medical Equipment are not subject to the annual dollar limit stated in the Schedule of

Benefits,

however Benefits continue to be subject to the limitation of a single purchase of a type of DME

(including

repair/replacement)

every three

years.

Hearing Aids

Benefits for hearing aids are not subject to the annual dollar limit stated in the Schedule of Benefits,

however

Benefits continue to be subject to the limitation of a single purchase (including repair/repla cement) per

hearing

impaired ear every three

years.

Prosthetic Devices

Benefits for prosthetic devices are not subject to the annual dollar limit stated in the Schedule of Benefits,

however

Benefits continue to be subject to the limitation of a single purchase of each type of prosthetic device every

three

years.

UnitedHealthcare Insurance

Company

President

RDR.RX.PLS.I.11.WI

1

Outpatient Prescription Drug

Rider

UnitedHealthcare Insurance

Company

This Rider to the Policy is issued to the Enrolling Group and provides Benefits for Prescription Drug Products.

Because this Rider is part of a legal document, we want to give you information about the document that will help

you understand it. Certain capitalized words have special meanings. We have defined these words in either the

Certificate

of Coverage

(Certificate)

in Section 9: Defined Terms or in this Rider in Section 3: Defined Terms.

When we use the words "we," "us," and "our" in this document, we are referring to UnitedHealthcare Insurance

Company. When we use the words "you" and "your" we are referring to people who are Covered Persons, as the

term is defined in the

Certificate

in Section 9: Defined Terms.

NOTE: The Coordination of Benefits provision in the Certificate in Section 7: Coordination of Benefits applies to

Prescription Drug Products covered through this Rider. Benefits for Prescription Drug Products will be

coordinated with those of any other health plan in the same manner as Benefits for Covered Health Services

described in the Certificate.

UnitedHealthcare Insurance

Company

President

RDR.RX.PLS.I.11.WI

2

Introduction

Coverage Policies and Guidelines

Our Prescription Drug List (PDL) Management Committee is authorized to make tier placement changes on

our

behalf. The PDL Management Committee makes the final classification of an FDA-approved Prescription

Drug

Product to a certain tier by considering a number of factors including, but not limited to, clinical and

economic

factors. Clinical factors may include, but are not limited to, evaluations of the place in therapy, relative safety

or

relative efficacy of the Prescription Drug Product, as well as whether certain supply limits or prior

authorization

requirements should apply. Economic factors may include, but are not limited to, the Prescription Drug

Product’s

acquisition cost including, but not limited to, available rebates and assessments on the cost effectiveness of

the

Prescription Drug

Product.

Some Prescription Drug Products are more cost effective for specific indications as compared to

others;

therefore, a Prescription Drug Product may be listed on multiple tiers according to the indication for which

the

Prescription Drug Product was prescribed, or according to whether it was prescribed by a Specialist

Physician.

We may periodically change the placement of a Prescription Drug Product among the tiers. These

changes

generally will occur quarterly, but no more than six times per calendar year. These changes may occur

without

prior notice to

you.

When considering a Prescription Drug Product for tier placement, the PDL Management Committee

reviews

clinical and economic factors regarding Covered Persons as a general population. Whether a

particular

Prescription Drug Product is appropriate for an individual Covered Person is a determination that is made by

the

Covered Person and the prescribing

Physician.

NOTE: The tier status of a Prescription Drug Product may change periodically based on the process

described

above. As a result of such changes, you may be required to pay more or less for that Prescription Drug

Product.

Please access www.myuhc.com through the Internet or call Customer Care at the telephone number on your

ID

card for the most up-to-date tier

status.

Identification Card (ID Card) - Network Pharmacy

You must either show your ID card at the time you obtain your Prescription Drug Product at a Network Pharmacy

or you must provide the Network Pharmacy with identifying information that can be verified by us during regular

business hours.

If you don’t show your ID card or provide verifiable information at a Network Pharmacy, you will be required to

pay the Usual and Customary Charge for the Prescription Drug Product at the pharmacy.

You may seek reimbursement from us as described in the Certificate in Section 5: How to File a Claim. When you

submit a claim on this basis, you may pay more because you failed to verify your eligibility when the Prescription

Drug Product was dispensed. The amount you are reimbursed will be based on the Prescription Drug Charge,

less the required Copayment and/or Coinsurance, Ancillary Charge, and any deductible that

applies.

Submit your claim to the Pharmacy Benefit Manager claims address noted on your ID

card.

Designated Pharmacies

If you require certain Prescription Drug Products, including, but not limited to, Specialty Prescription

Drug

Products, we may direct you to a Designated Pharmacy with whom we have an arrangement to provide

those

Prescription Drug

Products.

If you are directed to a Designated Pharmacy and you choose not to obtain your Prescriptio n Drug Product

from

a Designated Pharmacy, you will be subject to the non-Network Benefit for that Prescription Drug

Product.

RDR.RX.PLS.I.11.WI

3

Limitation on Selection of Pharmacies

If we determine that you may be using Prescription Drug Products in a harmful or abusive manner, or

with

harmful frequency, your selection of Network Pharmacies may be limited. If this happens, we may require you

to

select a single Network Pharmacy that will provide and coordinate all future pharmacy services. Benefits will

be

paid only if you use the designated single Network Pharmacy. If you don’t make a selection within 31 days of

the

date we notify you, we will select a single Network Pharmacy for

you.

Rebates and Other Payments

We may receive rebates for certain drugs included on the Prescription Drug List. We do not pass these rebates on

to you, nor are they taken into account in determining your Copayments and/or Coinsurance.

We, and a number of our affiliated entities, conduct business with various pharmaceutical manufacturers separate

and apart from this Outpatient Prescription Drug Rider. Such business may include, but is not limited to, data

collection, consulting, educational grants and research. Amounts received from pharmaceutical manufacturers

pursuant to such arrangements are not related to this Outpatient Prescription Drug Rider. We are not required to

pass on to you, and do not pass on to you, such amounts.

Coupons, Incentives and Other Communications

At various times, we may send mailings to you or to your Physician that communicate a variety of messages,

including information about Prescription Drug Products. These mailings may contain coupons or offers

from

pharmaceutical manufacturers that enable you, at your discretion, to purchase the described drug product at

a

discount or to obtain it at no charge. Pharmaceutical manufacturers may pay for and/or provide the content

for

these mailings. Only your Physician can determine whether a change in your Prescription Order or Refill

is

appropriate for your medical

condition.

Special Programs

We may have certain programs in which you may receive an enhanced or reduced Benefit based on your

actions

such as

adherence/compliance

to medication or treatment regimens, and/or participation in health

management

programs. You may access information on these programs through the Internet at www.myuhc.com or by

calling

Customer Care at the telephone number on your ID

card.

Prescription Drug Products Prescribed by a Specialist Physician

You may receive an enhanced or reduced Benefit, or no Benefit, based on whether the Prescription Drug Product

was prescribed by a Specialist Physician. You may access information on which Prescription Drug Products are

subject to Benefit enhancement, reduction or no Benefit through the Internet at

www.myuhc.com or by calling

Customer Care at the telephone number on your ID card.

RDR.RX.PLS.I.11.WI

4

Outpatient Prescription Drug Rider Table of Contents

Section 1: Benefits for Prescription Drug Products .............................. 5

Section 2: Exclusions ............................................................................... 6

Section 3: Defined Terms ......................................................................... 8

RDR.RX.PLS.I.11.WI

5

Section 1: Benefits for Prescription Drug

Products

Benefits are available for Prescription Drug Products at either a Network Pharmacy or a non-Network Pharmacy

and are subject to Copayments and/or Coinsurance or other payments that vary depending on which of the tiers

of the Prescription Drug List the Prescription Drug Product is listed. Refer to the Outpatient Prescription Drug

Schedule of Benefits for applicable Copayments and/or Coinsurance requirements.

Benefits for Prescription Drug Products are available when the Prescription Drug Product meets the definition of a

Covered Health Service or is prescribed to prevent conception.

Specialty Prescription Drug Products

Benefits are provided for Specialty Prescription Drug Products.

If you require Specialty Prescription Drug Products, we may direct you to a Designated Pharmacy with whom we

have an arrangement to provide those Specialty Prescription Drug Products.

If you are directed to a Designated Pharmacy and you choose not to obtain your Specialty Prescription Drug

Product from a Designated Pharmacy, you will be subject to the non-Network Benefit for that Specialty

Prescription Drug Product.

Please see Section 3: Defined Terms for a full description of Specialty Prescription Drug Product and Designated

Pharmacy.

Refer to the Outpatient Prescription Drug Schedule of Benefits for details on Specialty Prescription Drug

Product

supply

limits.

Prescription Drugs from a Retail Network Pharmacy

Benefits are provided for Prescription Drug Products dispensed by a retail Network

Pharmacy.

Refer to the Outpatient Prescription Drug Schedule of Benefits for details on retail Network Pharmacy supply

limits.

Prescription Drugs from a Retail Non-Network Pharmacy

Benefits are provided for Prescription Drug Products dispensed by a retail non-Network

Pharmacy.

If the Prescription Drug Product is dispensed by a retail non-Network Pharmacy, you must pay for

the

Prescription Drug Product at the time it is dispensed and then file a claim for reimbursem ent with us,

as

described in your Certificate, Section 5: How to File a Claim. We will not reimburse you for the difference

between

the Predominant Reimbursement Rate and the non-Network Pharmacy’s Usual and Customary Charge for

that

Prescription Drug Product. We will not reimburse you for any non-covered drug

product.

In most cases, you will pay more if you obtain Prescription Drug Products from a non-Network

Pharmacy.

Refer to the Outpatient Prescription Drug Schedule of Benefits for details on retail non-Network Pharmacy

supply

limits.

Prescription Drug Products from a Mail Order Network Pharmacy

Benefits are provided for certain Prescription Drug Products dispensed by a mail order Network

Pharmacy.

Refer to the Outpatient Prescription Drug Schedule of Benefits for details on mail order Network Pharmacy

supply

limits.

Please access www.myuhc.com through the Internet or call Customer Care at the telephone number on your

ID

card to determine if Benefits are provided for your Prescription Drug Product and for information on how

to

obtain your Prescription Drug Product through a mail order Network

Pharmacy.

RDR.RX.PLS.I.11.WI

6

Section 2: Exclusions

Exclusions from coverage listed in the Certificate apply also to this Rider, except that any preexisting condition

exclusion in the

Certificate

is not applicable to this Rider. In addition, the exclusions listed below apply.

When an exclusion applies to only certain Prescription Drug Products, you can access www.myuhc.com through

the Internet or call Customer Care at the telephone number on your ID card for information on which Prescription

Drug Products are excluded.

1. Coverage for Prescription Drug Products for the amount dispensed (days’ supply or quantity limit) which

exceeds the supply limit.

2. Coverage for Prescription Drug Products for the amount dispensed (days’ supply or quantity limit) which

is less than the minimum supply limit.

3. Prescription Drug Products dispensed outside the United States, except as required for Emergency

treatment.

4. Drugs which are prescribed, dispensed or intended for use during an Inpatient Stay.

5. Experimental or Investigational or Unproven Services and medications; medications used for experimental

indications and/or dosage regimens determined by us to be experimental, investigational or unproven.

This exclusion does not apply to Prescription Drug Products that are prescribed by a Physician for the

treatment of HIV infection, illness or medical condition arising from or related to HIV infection, if

the

medication is approved by the FDA and prescribed and administered in accordance with the

treatment

protocol approved for Investigational new

drug.

6. 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.

7. 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.

8. Any product dispensed for the purpose of appetite suppression or weight

loss.

9. A Pharmaceutical Product for which Benefits are provided in your

Certificate.

This exclusion does

not

apply to Depo Provera and other injectable drugs used for

contraception.

10. Durable Medical Equipment. Prescribed and non-prescribed outpatient supplies, other than the

diabetic

supplies and inhaler spacers specifically stated as

covered.

11. General vitamins, except the following which require a Prescription Order or Refill: prenatal

vitamins,

vitamins with fluoride, and single entity

vitamins.

12. Unit dose packaging of Prescription Drug

Products.

13. Medications used for cosmetic

purposes.

14. Prescription Drug Products, including New Prescription Drug Products or new dosage forms, that

we

determine do not meet the definition of a Covered Health

Service.

15. Prescription Drug Products as a replacement for a previously dispensed Prescription Drug Product

that

was lost, stolen, broken or

destroyed.

16. Prescription Drug Products when prescribed to treat

infertility.

17. Prescription Drug Products for smoking

cessation.

18. Compounded drugs that do not contain at least one ingredient that has been approved by the U.S. Food

and Drug Administration (FDA) and requires a Prescription Order or Refill. Compounded drugs that are

available as a similar commercially available Prescription Drug Product. (Compounded drugs that contain

at least one ingredient that requires a Prescription Order or Refill are assigned to Tier 3.)

RDR.RX.PLS.I.11.WI

7

19. Drugs available over-the-counter that do not require a Prescription Order or Refill by federal or state law

before being dispensed, unless we have designated the over-the-counter medication as eligible for

coverage as if it were a Prescription Drug Product and it is obtained with a Prescription Order or Refill

from a Physician. Prescription Drug Products that are available in over-the-counter form or comprised of

components that are available in over-the-counter form or equivalent. Certain Prescription Drug Products

that we have determined are Therapeutically Equivalent to an over-the-counter drug. Such determinations

may be made up to six times during a calendar year, and we may decide at any time to reinstate Benefits

for a Prescription Drug Product that was previously excluded under this provision.

20. Certain New Prescription Drug Products and/or new dosage forms until the date they are reviewed and

assigned to a tier by our PDL Management Committee.

21. Growth hormone for children with familial short stature (short stature based upon heredity and not caused

by a diagnosed medical condition).

22. Any product for which the primary use is a source of nutrition, nutritional supplements, or dietary

management of disease, even when used for the treatment of Sickness or Injury.

23. A Prescription Drug Product that contains (an) active ingredient(s) available in and Therapeutically

Equivalent to another covered Prescription Drug Product. Such determinations may be made up to six

times during a calendar year, and we may decide at any time to reinstate Benefits for a Prescription Drug

Product that was previously excluded under this provision.

24. A Prescription Drug Product that contains (an) active ingredient(s) which is (are) a modified version of

and

Therapeutically Equivalent to another covered Prescription Drug Product. Such determinations may

be

made up to six times during a calendar year, and we may decide at any time to reinstate Benefits for

a

Prescription Drug Product that was previously excluded under this

provision.

25. Certain Prescription Drug Products that have not been prescribed by a Specialist

Physician.

RDR.RX.PLS.I.11.WI

8

Section 3: Defined

Terms

Ancillary Charge - a charge, in addition to the Copayment and/or Coinsurance, that you are required to pay

when a covered Prescription Drug Product is dispensed at your or the provider’s request, when a Chemically

Equivalent Prescription Drug Product is available on a lower tier. For Prescription Drug Products from Network

Pharmacies, the Ancillary Charge is calculated as the difference between the Prescription Drug Charge or

Maximum Allowable Cost (MAC) List price for Network Pharmacies for the Prescription Drug Product on the

higher tier, and the Prescription Drug Charge or Maximum Allowable Cost (MAC) List price of the Chemically

Equivalent Prescription Drug Product available on the lower tier. For Prescription Drug Products from

non-Network Pharmacies, the Ancillary Charge is calculated as the difference between the Predominant

Reimbursement Rate or Maximum Allowable Cost (MAC) List price for non-Network Pharmacies for the

Prescription Drug Product on the higher tier, and the Predominant Reimbursement Rate or Maximum Allowable

Cost (MAC) List price of the Chemically Equivalent Prescription Drug Product available on the lower tier.

Brand-name - a Prescription Drug Product: (1) which is manufactured and marketed under a trademark or name

by a specific drug manufacturer; or (2) that we identify as a Brand-name product, based on available data

resources including, but not limited to, First DataBank, that classify drugs as either brand or generic based on a

number of factors. You should know that all products identified as a "brand name" by the manufacturer,

pharmacy, or your Physician may not be classified as Brand-name by us.

Chemically Equivalent - when Prescription Drug Products contain the same active ingredient.

Designated Pharmacy - a pharmacy that has entered into an agreement with us or with an

organization

contracting on our behalf, to provide specific Prescription Drug Products, including, but not limited to,

Specialty

Prescription Drug Products. The fact that a pharmacy is a Network Pharmacy does not mean that it is

a

Designated

Pharmacy.

Generic - a Prescription Drug Product: (1) that is Chemically Equivalent to a Brand-name drug; or (2) that

we

identify as a Generic product based on available data resources including, but not limited to, First DataBank,

that

classify drugs as either brand or generic based on a number of factors. You should know that all

products

identified as a "generic" by the manufacturer, pharmacy or your Physician may not be classified as a Generic

by

us.

Network Pharmacy - a pharmacy that

has:

Entered into an agreement with us or an organization contracting on our behalf to provide Prescription Drug

Products to Covered Persons.

Agreed to accept specified reimbursement rates for dispensing Prescription Drug

Products.

Been

designated by us as a Network

Pharmacy.

New Prescription Drug Product - a Prescription Drug Product or new dosage form of a previously

approved

Prescription Drug Product, for the period of time starting on the date the Prescription Drug Product or

new

dosage form is approved by the U.S. Food and Drug Administration (FDA) and ending on the earlier of

the

following

dates:

The date it is assigned to a tier by our PDL Management

Committee.

December 31st of the following calendar year.

Out-of-Pocket Drug Maximum - the maximum amount you are required to pay for covered Prescription Drug

Products in a single year. Refer to the Outpatient Prescription Drug Schedule of Benefits for details about how the

Out-of-Pocket Drug Maximum applies.

Predominant Reimbursement Rate - the amount we will pay to reimburse you for a Prescription Drug Product

that is dispensed at a non-Network Pharmacy. The Predominant Reimbursement Rate for a particular

Prescription Drug Product dispensed at a non-Network Pharmacy includes a dispensing fee and any applicable

sales tax. We calculate the Predominant Reimbursement Rate using our Prescription Drug Charge that applies for

that particular Prescription Drug Product at most Network Pharmacies.

Prescription Drug Charge - the rate we have agreed to pay our Network Pharmacies, including the applicable

dispensing fee and any applicable sales tax, for a Prescription Drug Product dispensed at a Network Pharmacy.

Prescription Drug List - a list that categorizes into tiers medications, products or devices that have been

approved by the U.S. Food and Drug Administration (FDA). This list is subject to our periodic review and

RDR.RX.PLS.I.11.WI

9

modification (generally quarterly, but no more than six times per calendar year). You may determine to which tier

a particular Prescription Drug Product has been assigned through the Internet at www.myuhc.com or by calling

Customer Care at the telephone number on your ID card.

Prescription Drug List (PDL) Management Committee - the committee that we designate for, among other

responsibilities, classifying Prescription Drug Products into specific tiers.

Prescription Drug Product - a medication, product or device that has been approved by the U.S. Food and Drug

Administration

(FDA) and that can, under federal or state law, be dispensed only pursuant to a Prescription Order

or Refill. A Prescription Drug Product includes a medication that, due to its characteristics, is appropriate for

self-administration or administration by a non-skilled caregiver. For the purpose of Benefits under the Policy, this

definition includes:

Inhalers (with spacers).

Insulin.

The following diabetic supplies:

standard insulin syringes with needles;

blood-testing strips - glucose;

urine-testing strips - glucose;

ketone-testing strips and tablets;

lancets and lancet devices;

and

glucose

monitors.

Prescription Order or Refill - the directive to dispense a Prescription Drug Product issued by a duly

licensed

health care provider whose scope of practice permits issuing such a

directive.

Preventive Care Medications - the medications that are obtained at a Network Pharmacy with a

Prescription

Order or Refill from a Physician and that are payable at 100% of the cost (without application of any

Copayment,

Coinsurance, Annual Deductible, Annual Drug Deductible or Specialty Prescription Drug Product

Annual

Deductible) as required by applicable law under any of the

following:

Evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of

the United States Preventive Services Task Force.

With respect to infants, children and adolescents, evidence-informed preventive care and

screenings

provided for in the comprehensive guidelines supported by the Health Resources and Services

Administration.

With respect to women, such additional preventive care and screenings as provided for in

comprehensive

guidelines supported by the Health Resources and Services Administration.

You may determine whether a drug is a Preventive Care Medication through the internet at www.myuhc.com

or

by calling Customer Care at the telephone number on your ID

card.

Specialty Prescription Drug Product - Prescription Drug Products that are generally high cost,

self-administered

biotechnology drugs used to treat patients with certain illnesses. You may access a complete list of

Specialty

Prescription Drug Products through the Internet at www.myuhc.com or by calling Customer Care at the

telephone

number on your ID

card.

Therapeutic Class - a group or category of Prescription Drug Products with similar uses and/or

actions.

Therapeutically Equivalent - when Prescription Drug Products have essentially the same efficacy and

adverse

effect

profile.

Usual and Customary Charge - the usual fee that a pharmacy charges individuals for a Prescription

Drug

Product without reference to reimbursement to the pharmacy by third parties. The Usual and Customary

Charge

includes a dispensing fee and any applicable sales tax.

RDR.RXSBN.PLS.I.11.WI

1

Outpatient Prescription

Drug

UnitedHealthcare Insurance

Company

Schedule of

Benefits

Benefits for Prescription Drug Products

Benefits are available for Prescription Drug Products at either a Network Pharmacy or a non-Network

Pharmacy

and are subject to Copayments and/or Coinsurance or other payments that vary depending on which of the

tiers

of the Prescription Drug List the Prescription Drug Product is

listed.

Benefits for Prescription Drug Products are available when the Prescription Drug Product meets the definition of

a

Covered Health Service or is prescribed to prevent

conception.

If a Brand-name Drug Becomes Available as a Generic

If a Generic becomes available for a Brand-name Prescription Drug Product, the tier placement of the

Brand-name Prescription Drug Product may change, and therefore your Copayment and/or Coinsurance may

change and an Ancillary Charge may apply. You will pay the Copayment and/or Coinsurance applicable for the

tier to which the Prescription Drug Product is assigned.

Supply Limits

Benefits for Prescription Drug Products are subject to the supply limits that are stated in the "Description

and

Supply Limits" column of the Benefit Information table. For a single Copayment and/or Coinsurance, you

may

receive a Prescription Drug Product up to the stated supply

limit.

Note: Some products are subject to additional supply limits based on criteria that we have developed, subject

to

our periodic review and modification. The limit may restrict the amount dispensed per Prescription Order or

Refill

and/or the amount dispensed per month’s supply, or may require that a minimum amount be

dispensed.

You may determine whether a Prescription Drug Product has been assigned a supply limit for dispensing

through

the Internet at www.myuhc.com or by calling Customer Care at the telephone number on your ID

card.

Prior Authorization Requirements

Before certain Prescription Drug Products are dispensed to you, either your Physician, your pharmacist or

you

are required to obtain prior authorization from us or our designee. The reason for obtaining prior

authorization

from us is to determine whether the Prescription Drug Product, in accordance with our approved guidelines, is

each of the following:

It meets the definition of a Covered Health

Service.

It is not an Experimental or Investigational or Unproven

Service.

We may also require you to obtain prior authorization from us or our designee so we can determine whether

the

Prescription Drug Product, in accordance with our approved guidelines, was prescribed by a

Specialist

Physician.

Network Pharmacy Prior Authorization

When Prescription Drug Products are dispensed at a Network Pharmacy, the prescribing provider,

the

pharmacist, or you are responsible for obtaining prior authorization from

us.

RDR.RXSBN.PLS.I.11.WI

2

Non-Network Pharmacy Prior Authorization

When Prescription Drug Products are dispensed at a non-Network Pharmacy, you or your Physician are

responsible for obtaining prior authorization from us as required.

If you do not obtain prior authorization from us before the Prescription Drug Product is dispensed, you may pay

more for that Prescription Order or Refill. The Prescription Drug Products requiring prior authorization are subject

to our periodic review and modification. You may determine whether a particular Prescription Drug Product

requires prior authorization through the Internet at www.myuhc.com or by calling Customer Care at the telephone

number on your ID card.

If you do not obtain prior authorization from us before the Prescription Drug Product is dispensed, you can ask

us to consider reimbursement after you receive the Prescription Drug Product. You will be required to pay for the

Prescription Drug Product at the pharmacy. Our contracted pharmacy reimbursement rates (our Prescription

Drug Charge) will not be available to you at a non-Network Pharmacy. You may seek reimbursement from us as

described in the

Certificate

of Coverage

(Certificate)

in Section 5: How to File a Claim.

When you submit a claim on this basis, you may pay more because you did not obtain prior authorization from

us before the Prescription Drug Product was dispensed. The amount you are reimbursed will be based on the

Prescription Drug Charge (for Prescription Drug Products from a Network Pharmacy) or the Predominant

Reimbursement Rate (for Prescription Drug Products from a non-Network Pharmacy), less the required

Copayment and/or Coinsurance, Ancillary Charge and any deductible that applies.

Benefits may not be available for the Prescription Drug Product after we review the documentation provided

and

we determine that the Prescription Drug Product is not a Covered Health Service or it is an Experimental

or

Investigational or Unproven Service, except as stated in Section 2: Exclusions of the Prescription Drug

Rider.

We may also require prior authorization for certain programs which may have specific requirements

for

participation and/or activation of an enhanced level of Benefits associated with such programs. You may

access

information on available programs and any applicable prior authorization, participation or activation

requirements

associated with such programs through the Internet at www.myuhc.com or by calling Customer Care at

the

telephone number on your ID

card.

Step Therapy

Certain Prescription Drug Products for which Benefits are described under this Prescription Drug Rider

or

Pharmaceutical Products for which Benefits are described in your Certificate are subject to step

therapy

requirements. This means that in order to receive Benefits for such Prescription Drug Products

and/or

Pharmaceutical Products you are required to use a different Prescription Drug Product(s) or

Pharmaceutical

Product(s)

first.

You may determine whether a particular Prescription Drug Product or Pharmaceutical Product is subject to

step

therapy requirements through the Internet at www.myuhc.com or by calling Customer Care at the

telephone

number on your ID

card.

What You Must Pay

You are responsible for paying the applicable Copayment and/or Coinsurance described in the

Benefit

Information table, in addition to any Ancillary

Charge.

You are not responsible for paying a Copayment and/or Coinsurance for Preventive Care

Medications.

An Ancillary Charge may apply when a covered Prescription Drug Product is dispensed at your or the

provider’s

request and there is another drug that is chemically the same available at a lower tier. When you choose

the

higher tiered drug of the two, you will pay the difference between the higher tiered drug and the lower tiered

drug

in addition to your Copayment and/or Coinsurance that applies to the lower tiered

drug.

The amount you pay for any of the following under this Rider will not be included in calculating any

Out-of-Pocket

Maximum stated in your

Certificate:

Copayments for Prescription Drug Products, including Specialty Prescription Drug Products.

Ancillary Charges.

The difference between the Predominant Reimbursement Rate and a non-Network Pharmacy’s Usual

and

Customary Charge for a Prescription Drug

Product.

RDR.RXSBN.PLS.I.11.WI

3

Any non-covered drug product. You are responsible for paying 100% of the cost (the amount the pharmacy

charges you) for any non-covered drug product and our contracted rates (our Prescription Drug Charge) will

not be available to you.

RDR.RXSBN.PLS.I.11.WI

4

Payment Information

The Out-of-Pocket Drug Maximums are calculated on a calendar year

basis.

Payment Term And Description

Amounts

Out-of-Pocket Drug Maximum

The maximum amount you are required

to

pay for covered Prescription Drug

Products

in a single year. Once you reach

the

Out-of-Pocket Drug Maximum, you will

not

be required to pay Copayments

or

Coinsurance for covered Prescription

Drug

Products for the remainder of the

year.

Network and Non-Network

$2,500 per Covered Person, not to exceed $5,000 for all

Covered

Persons in a

family.

Copayment and Coinsurance

Copayment

Copayment for a Prescription Drug

Product

at a Network or non-Network Pharmacy is

a

specific dollar

amount.

Coinsurance

Coinsurance for a Prescription Drug

Product

at a Network Pharmacy is a percentage

of

the Prescription Drug

Charge.

Coinsurance for a Prescription

Drug

Product at a non-Network Pharmacy is

a

percentage of the

Predominant

Reimbursement

Rate.

Copayment and Coinsurance

Your Copayment and/or Coinsurance

is

determined by the tier to which

the

Prescription Drug List (PDL)

Management

Committee has assigned a

Prescription

Drug Product.

Special Programs: We may have certain

programs in which you may receive a

reduced or increased Copayment and/or

Coinsurance based on your actions such as

adherence/compliance to medication or

treatment regimens, and/or participation in

health management programs. You may

access information on these programs

through the Internet at www.myuhc.com or

by calling Customer Care at the telephone

number on your ID card.

Prescription Drug Products Prescribed by

a Specialist Physician: You may receive a

reduced or increased Copayment and/or

For Prescription Drug Products at a retail Network Pharmacy,

you

are responsible for paying the lower of the

following:

The applicable Copayment and/or

Coinsurance.

The Network Pharmacy’s Usual and Customary Charge

for

the Prescription Drug

Product.

For Prescription Drug Products from a mail order

Network

Pharmacy, you are responsible for paying the lower of

the

following:

The applicable Copayment and/or Coinsurance.

The Prescription Drug Charge for that Prescription Drug

Product.

See the Copayments and/or Coinsurance stated in the Benefit

Information table for amounts.

You are not responsible for paying a Copayment and/or

Coinsurance for Preventive Care Medications.

RDR.RXSBN.PLS.I.11.WI

5

Payment Term And Description

Amounts

Coinsurance based on whether the

Prescription Drug Product was prescribed

by a Specialist Physician. You may access

information on which Prescription Drug

Products are subject to a reduced or

increased Copayment and/or Coinsurance

through the Internet at www.myuhc.com or

by calling Customer Care at the telephone

number on your ID card.

NOTE: The tier status of a Prescription

Drug Product can change periodically,

generally quarterly but no more than six

times per calendar year, based on the

Prescription Drug List (PDL) Management

Committee’s periodic tiering decisions.

When that occurs, you may pay more

or

less for a Prescription Drug

Product,

depending on its tier assignment.

Please

access www.myuhc.com through

the

Internet or call Customer Care at

the

telephone number on your ID card for

the

most up-to-date tier

status.

RDR.RXSBN.PLS.I.11.WI

6

Benefit Information

Description and Supply Limits

Benefit (The Amount We Pay)

Specialty Prescription Drug Products

The following supply limits

apply.

As written by the provider, up to a

consecutive 31-day supply of a Specialty

Prescription Drug Product, unless

adjusted based on the drug

manufacturer’s packaging size, or based

on supply limits.

When a Specialty Prescription Drug Product

is packaged or designed to deliver in a

manner that provides more than a

consecutive 31-day supply, the

Copayment

and/or Coinsurance that applies will

reflect

the number of days

dispensed.

Supply limits apply to Specialty

Prescription

Drug Products obtained at a

Network

Pharmacy, a non-Network Pharmacy, or

a

Designated

Pharmacy.

Your Copayment and/or Coinsurance is determined by the tier

to

which the Prescription Drug List (PDL) Management

Committee

has assigned the Specialty Prescription Drug Product.

All

Specialty 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 Customer Care at

the

telephone number on your ID card to determine tier

status.

Network Pharmacy

For a Tier 1 Specialty Prescription Drug Product: 100% of

the

Prescription Drug Charge after you pay a Copayment of $10

per

Prescription Order or

Refill.

For a Tier 2 Specialty Prescription Drug Product: 100% of

the

Prescription Drug Charge after you pay a Copayment of $100

per

Prescription Order or

Refill.

For a Tier 3 Specialty Prescription Drug Product: 100% of

the

Prescription Drug Charge after you pay a Copayment of $300

per

Prescription Order or

Refill.

Non-Network Pharmacy

For a Tier 1 Specialty Prescription Drug Product: 100% of

the

Predominant Reimbursement Rate after you pay a Copayment

of

$10 per Prescription Order or

Refill.

For a Tier 2 Specialty Prescription Drug Product: 100% of

the

Predominant Reimbursement Rate after you pay a Copayment

of

$100 per Prescription Order or

Refill.

For a Tier 3 Specialty Prescription Drug Product: 100% of

the

Predominant Reimbursement Rate after you pay a Copayment

of

$300 per Prescription Order or

Refill.

Prescription Drugs from a Retail Network

Pharmacy

The following supply limits apply:

As written by the provider, up to

a

consecutive 31-day supply of

a

Prescription Drug Product,

unless

adjusted based on the

drug

manufacturer’s packaging size, or

based

on supply

limits.

A one-cycle supply of a contraceptive.

You may obtain up to three cycles at one

time if you pay a Copayment and/or

Coinsurance for each cycle supplied.

Your Copayment and/or Coinsurance is determined by the tier to

which the Prescription Drug List (PDL) 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 Customer Care at the telephone number on your ID card to

determine tier status.

For a Tier 1 Prescription Drug Product: 100% of the Prescription

Drug Charge after you pay a Copayment of $10 per Prescription

Order or Refill.

For a Tier 2 Prescription Drug Product: 100% of the Prescription

Drug Charge after you pay a Copayment of $35 per Prescription

RDR.RXSBN.PLS.I.11.WI

7

Description and Supply Limits

Benefit (The Amount We Pay)

When a Prescription Drug Product is

packaged or designed to deliver in a

manner that provides more than a

consecutive 31-day supply, the Copayment

and/or Coinsurance that applies will reflect

the number of days dispensed.

Order or Refill.

For a Tier 3 Prescription Drug Product: 100% of the Prescription

Drug Charge after you pay a Copayment of $60 per Prescription

Order or Refill.

Prescription Drugs from a Retail

Non-Network Pharmacy

The following supply limits apply:

As written by the provider, up to a

consecutive 31-day supply of a

Prescription Drug Product, unless

adjusted based on the drug

manufacturer’s packaging size, or based

on supply limits.

A one-cycle supply of a contraceptive.

You may obtain up to three cycles at one

time if you pay a Copayment and/or

Coinsurance for each cycle supplied.

When a Prescription Drug Product is

packaged or designed to deliver in a

manner that provides more than a

consecutive 31-day supply, the Copayment

and/or Coinsurance that applies will reflect

the number of days dispensed.

Your Copayment and/or Coinsurance is determined by the tier to

which the Prescription Drug List (PDL) 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 Customer Care at the telephone number on your ID card

to

determine tier

status.

For a Tier 1 Prescription Drug Product: 100% of the

Predominant

Reimbursement Rate after you pay a Copayment of $10

per

Prescription Order or

Refill.

For a Tier 2 Prescription Drug Product: 100% of the

Predominant

Reimbursement Rate after you pay a Copayment of $35

per

Prescription Order or

Refill.

For a Tier 3 Prescription Drug Product: 100% of the

Predominant

Reimbursement Rate after you pay a Copayment of $60

per

Prescription Order or

Refill.

Prescription Drug Products from a Mail

Order Network Pharmacy

The following supply limits apply:

As written by the provider, up to a

consecutive 90-day supply of a

Prescription Drug Product, unless

adjusted based on the drug

manufacturer’s packaging size, or based

on supply limits. These supply limits do

not apply to Specialty Prescription Drug

Products. Specialty Prescription Drug

Products from a mail order Network

Pharmacy are subject to the supply

limits stated above under the

heading

Specialty Prescription

Drug

Products.

You may be required to fill an initial

Prescription Drug Product order and obtain

1 refill through a retail pharmacy prior to

using a mail order Network Pharmacy.

To maximize your Benefit, ask

your

Your Copayment and/or Coinsurance is determined by the tier to

which the Prescription Drug List (PDL) 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 Customer Care at the telephone number on your ID card

to

determine tier

status.

For up to a 90-day supply, we

pay:

For a Tier 1 Prescription Drug Product: 100% of the

Prescription

Drug Charge after you pay a Copayment of $25 per

Prescription

Order or

Refill.

For a Tier 2 Prescription Drug Product: 100% of the

Prescription

Drug Charge after you pay a Copayment of $87.50

per

Prescription Order or

Refill.

For a Tier 3 Prescription Drug Product: 100% of the

Prescription

Drug Charge after you pay a Copayment of $150 per

Prescription

Order or Refill.

RDR.RXSBN.PLS.I.11.WI

8

Description and Supply Limits

Benefit (The Amount We Pay)

Physician to write your Prescription Order

or Refill for a 90-day supply, with

refills

when

appropriate. You will be charged a

mail order Copayment and/or Coinsurance

for any Prescription Orders or Refills sent to

the mail order pharmacy regardless of the

number-of-days’ supply written on the

Prescription Order or Refill. Be sure your

Physician writes your Prescription Order or

Refill for a 90-day supply, not a 30-day

supply with three refills.