UnitedHealthcare Choice Plus Certificate of Coverage

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UnitedHealthcare Choice Plus

Certificate of Coverage

UnitedHealthcare Insurance Company

What Is the Certificate of Coverage?

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

UnitedHealthcare Insurance Company and the Group. The Certificate describes Covered Health Care

Services, subject to the terms, conditions, exclusions and limitations of the Policy. We issue the Policy

based on the Group's Application and payment of the required Policy Charges.

In addition to this Certificate, the Policy includes:

• The Schedule of Benefits.

• The Group's Application.

• Riders, including the Outpatient Prescription Drug Rider, the Pediatric Dental Services Rider and

the Pediatric Vision Care Services Rider.

• Amendments.

You can review the Policy at the Group's office during regular business hours.

Can This Certificate Change?

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

Amendments that may change certain provisions of this Certificate. When this happens we will send you

a new Certificate, Rider or Amendment.

Other Information You Should Have

We have the right to change, interpret, withdraw or add Benefits, or to end the Policy, as permitted by

law, without your approval with a 60-day prior written notice. However, please note that all decisions

made by us are subject to the procedures described in Section 6: Questions, Complaints and Appeals.

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 shown in the Policy. Coverage under the Policy starts at 12:01 a.m.

and ends at 12:00 midnight in the time zone of the Group's location. The Policy will remain in effect as

long as the Policy Charges are paid when they are due, subject to Section 4: When Coverage Ends.

We are delivering the Policy in Maine. The Policy is subject to the laws of the state of Maine and ERISA,

unless the Group is not a private plan sponsor subject to ERISA. To the extent that state law applies,

Maine law governs the Policy.

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Introduction to Your Certificate

This Certificate and the other Policy documents describe your Benefits, as well as your rights and

responsibilities, under the Policy.

What Are Defined Terms?

Certain capitalized words have special meanings. We have defined these words in Section 9: 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 that term is defined in Section 9: Defined Terms.

How Do You Use This Document?

Read your entire Certificate and any attached Riders and/or Amendments. You may not have all of the

information you need by reading just one section. Keep your Certificate and Schedule of Benefits and any

attachments in a safe place for your future reference. You can also get this Certificate at

www.myuhc.com.

Review the Benefit limitations of this Certificate by reading the attached Schedule of Benefits along with

Section 1: Covered Health Care Services and Section 2: Exclusions and Limitations. Read Section 8:

General Legal Provisions to understand how this Certificate and your Benefits work. Call us if you have

questions about the limits of the coverage available to you.

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

Certificate controls.

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

How Do You Contact Us?

Call the telephone number listed on your identification (ID) card. Throughout the document you will find

statements that encourage you to contact us for more information.

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Your Responsibilities

Enrollment and Required Contributions

Benefits are available to you 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 and receive Benefits, both of the following apply:

• Your enrollment must be in accordance with the requirements of the Policy issued to your Group,

including the eligibility requirements.

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

Terms.

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

the Policy. If you have questions about this, contact your Group.

Be Aware the Policy Does Not Pay for All Health Care Services

The Policy does not pay for all health care services. Benefits are limited to Covered Health Care Services.

The Schedule of Benefits will tell you the portion you must pay for Covered Health Care Services.

Decide What Services You Should Receive

Care decisions are between you and your Physician. 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 your care. 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 Care Services require prior authorization. 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 Care Services from an out-of-Network provider, you are

responsible for obtaining prior authorization before you receive the services. For detailed information on

the Covered Health Care Services that require prior authorization, please refer to the Schedule of

Benefits.

Pay Your Share

You must meet any applicable deductible and pay a Co-payment and/or Co-insurance for most Covered

Health Care Services. These payments are due at the time of service or when billed by the Physician,

provider or facility. Any applicable deductible, Co-payment and Co-insurance amounts are listed in the

Schedule of Benefits.

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 the Policy's exclusions.

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Show Your ID Card

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

card, the provider may fail to bill the correct entity for the services delivered.

File Claims with Complete and Accurate Information

When you receive Covered Health Care Services from an out-of-Network provider, you are responsible

for requesting payment from us. You must file the claim in a format that contains all of the information 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 care services for that condition or disability until the prior

coverage ends. We will pay Benefits as of the day your coverage begins under the Policy for all other

Covered Health Care Services that are not related to the condition or disability for which you have other

coverage.

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Our Responsibilities

Determine Benefits

We make administrative decisions regarding whether the Policy 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 authority 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 assign this authority to other persons or entities that may provide administrative services for the

Policy, such as claims processing. The identity of the service providers and the nature of their services

may be changed from time to time as we determine. In order to receive Benefits, you must cooperate with

those service providers.

Pay for Our Portion of the Cost of Covered Health Care Services

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

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 Care Services. It also

means that not all of the health care services you receive may be paid for (in full or in part) by the Policy.

Pay Network Providers

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

Covered Health Care Services from Network providers, you do not have to submit a claim to us.

Pay for Covered Health Care Services Provided by Out-of-Network

Providers

In accordance with any state prompt pay requirements, we 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, as we determine, in accordance with one or more of the

following methodologies:

• As shown 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

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reimbursement policies) and the billed charge. However, out-of-Network providers 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 except when 1) the bill is considered a

surprise bill under Maine law; or 2) we approve an exception for you to see the out-of-Network provider

because our Network is not adequate. You may get copies of our reimbursement policies for yourself or

to share with your out-of-Network Physician or provider by contacting us at www.myuhc.com or the

telephone number on your ID card.

We may apply a reimbursement methodology established by OptumInsight and/or a third party vendor,

which is based on CMS coding principles, to determine appropriate reimbursement levels for Emergency

Health Care Services. The methodology is usually based on elements reflecting the patient complexity,

direct costs, and indirect costs of an Emergency Health Care Service. If the methodology(ies) currently in

use become no longer available, we will use a comparable methodology(ies). We and OptumInsight are

related companies through common ownership by UnitedHealth Group. Refer to our website at

www.myuhc.com for information regarding the vendor that provides the applicable methodology.

Protection from Surprise Bills

With respect to a surprise bill or a bill for covered Emergency Health Care Services rendered by an out-

of-Network provider:

A. We will require you to pay only the applicable Co-insurance, Co-payment, deductible or other out-

of-pocket expense that would be imposed for health care services if the services were rendered by

a Network provider. We will calculate any Co-insurance amount based on the median Network rate

for that service.

B. Except as provided for ambulance services, unless we and the out-of-Network provider agree

otherwise, we will reimburse the out-of-Network provider or enrollee, as applicable, for health care

services rendered at the greater of:

1. Our median Network rate paid for that service by a similar provider in the geographic area

where the service was provided; and

2. The median Network rate paid by all insurers for that service by a similar provider in the

geographic area where the service was provided as determined by the all-payer claims

database maintained by the Maine Health Data Organization or, if Maine Health Data

Organization claims data is insufficient or otherwise inapplicable, another independent medical

claims database specified by the superintendent.

C. If we have an inadequate Network, as determined by the superintendent, we will ensure that you

obtain the covered service at no greater cost to you than if the service were obtained from a

Network provider or will make other arrangements acceptable to the superintendent.

D. We will reimburse an out-of-Network provider for ambulance services that are covered Emergency

Health Care Services at the out-of-Network provider's rate required in accordance with Maine law.

E. If an out-of-Network provider disagrees with our payment amount for a surprise bill for Emergency

Health Care Services or for covered Emergency Health Care Services, we and the out-of-Network

provider have 30 calendar days to negotiate an agreement on the payment amount in good faith. If

we and the out-of-Network provider do not reach agreement on the payment amount within 30

calendar days, the out-of-Network provider may submit a dispute regarding the payment and

receive another payment from us determined in accordance with the dispute resolution process in

accordance with Maine law.

F. Your responsibility for payment for covered out-of-Network Emergency Health Care Services must

be limited so that if you have paid your share of the charge as specified in the plan for Network

services, we will hold the enrollee harmless from any additional amount owed to an out-of-Network

provider for covered Emergency Health Care Services and make payment to the out-of-Network

provider in accordance with this section or, if there is a dispute, in accordance with Maine law.

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Payment after resolution of disputes: following an independent dispute resolution determination in

accordance with Maine law, the determination by the independent dispute resolution entity of a

reasonable payment for a specific health care service or treatment rendered by an out-of-Network

provider is binding on us, out-of-Network provider and you for 90 days. During that 90-day period, we will

reimburse an out-of-Network provider at that same rate for that specific health care service or treatment,

and an out-of-Network provider may not dispute any bill for that service in accordance with Maine law.

As used in this section, "surprise bill" means a bill for health care services, including, but not limited to,

Emergency Health Care Services, received by you for Covered Health Care Services rendered by an out-

of-Network provider at a Network provider, when such services were rendered by that out-of-Network

provider at a Network provider, during a service or procedure performed by a Network provider, or during

a service or procedure previously approved or authorized us, and you did not knowingly elect to obtain

such services from that out-of-Network provider. A surprise bill does not include a bill for health care

services received by you when a Network provider was available the render the services and you

knowingly elected to obtain the services from another provider who was an out-of-Network provider.

As used in this section, "Knowingly elected to obtain such services from that out-of-Network provider"

means that you chose the services of a specific provider, with full knowledge that the provider is an out-

of-Network provider with respect to your health plan, under circumstances that indicate that you had and

was informed of the opportunity to receive services from a Network provider but instead selected the out-

of-Network provider. The disclosure by a provider of Network status does not render your decision to

proceed with treatment from that provider a choice made knowingly pursuant to this subsection.

Offer Health Education Services to You

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 take part in the programs, but we recommend that you discuss them with your Physician.

Explanation and Notice to Parent

If the Covered Person is an Enrolled Dependent child, and the parent of the Covered Person makes the

request, we will provide the parent with:

• Payment or denial of claim. An explanation of the payment or denial of any claim filed on behalf

of the Covered Person, except to the extent that the Covered Person has the right to withhold

consent and does not affirmatively consent to notifying the parent.

• Change in terms and conditions. An explanation of any proposed change in the terms and

conditions of the Policy.

• Notice of lapse. Reasonable notice that the Policy may lapse, but only if the parent has provided

us with the address at which the parent may be notified.

In addition, any parent who is able to provide the information necessary to us to process a claim will be

permitted to authorize the filing of any claim under the Policy.

Comparable Health Care Services Incentive Program

The Covered Person is encouraged to shop for low-cost, high-quality providers for comparable health

care services. "Comparable health care services" means nonemergency, outpatient health care services

in the following categories: (1) physical and occupational therapy services, (2) radiology and imaging

services, (3) laboratory services, and (4) infusion therapy services. If you need comparable health care

services, you are encouraged to contact one of our representatives by calling the telephone number on

Your ID card or emailing the email address on Your ID card. We can help you find a provider that is right

for you. In addition, for shopping and utilizing this program, you will receive a $25 gift card for each time

you shop a service category with a maximum of $200 for utilizing this program.

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Certificate of Coverage Table of Contents

Section 1: Covered Health Care Services ..............................................10

Section 2: Exclusions and Limitations...................................................34

Section 3: When Coverage Begins .........................................................46

Section 4: When Coverage Ends ............................................................50

Section 5: How to File a Claim ................................................................54

Section 6: Questions, Complaints and Appeals....................................56

Section 7: Coordination of Benefits .......................................................63

Section 8: General Legal Provisions ......................................................69

Section 9: Defined Terms ........................................................................78

Section 10: Travel and Lodging Program ..............................................91

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Section 1: Covered Health Care Services

When Are Benefits Available for Covered Health Care Services?

Benefits are available only when all of the following are true:

• The health care service, including supplies or Pharmaceutical Products, is only a Covered Health

Care Service if it is Medically Necessary. (See definitions of Medically Necessary and Covered

Health Care Service in Section 9: Defined Terms.)

• You receive Covered Health Care Services while the Policy is in effect.

• You receive Covered Health Care Services 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 Care Services is a Covered Person and meets all

eligibility requirements specified in the Policy.

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-related

and addictive disorders, disease or its symptoms does not mean that the procedure or treatment is a

Covered Health Care Service under the Policy.

Benefits are provided for services delivered via Telehealth. Benefits are also provided for Remote

Physiologic Monitoring. Benefits for these services are provided to the same extent as an in-person

service under any applicable Benefit category in this section unless otherwise specified in the Schedule of

Benefits. A Physician or other provider providing health care services through Telehealth must be acting

within the scope of practice of his or her license and complying with applicable standards of practice and

board rules regarding telehealth.

This section describes Covered Health Care 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 Care Services (including any Annual

Deductible, Co-payment and/or Co-insurance).

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

on services).

• Any limit that applies to the portion of the Allowed Amount or the Recognized Amount when

applicable, you are required to pay in a year (Out-of-Pocket Limit).

• 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 the required Emergency Health Care Services can be performed.

Non-Emergency ambulance transportation by a licensed ambulance service (either ground or Air

Ambulance, as we determine appropriate) between facilities only when the transport meets one of the

following:

• From an out-of-Network Hospital to the closest Network Hospital when Covered Health Care

Services are required.

• To the closest Network Hospital that provides the required Covered Health Care Services that were

not available at the original Hospital.

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• From a short-term acute care facility to the closest Network long-term acute care facility (LTAC),

Network Inpatient Rehabilitation Facility, or other Network sub-acute facility where the required

Covered Health Care Services can be delivered.

For the purpose of this Benefit the following terms have the following meanings:

• "Long-term acute care facility (LTAC)" means a facility or Hospital that provides care to people with

complex medical needs requiring long-term Hospital stay in an acute or critical setting.

• "Short-term acute care facility" means a facility or Hospital that provides care to people with

medical needs requiring short-term Hospital stay in an acute or critical setting such as for recovery

following a surgery, care following sudden Sickness, Injury, or flare-up of a chronic Sickness.

• "Sub-acute facility" means a facility that provides intermediate care on short-term or long-term

basis.

2. Autism Spectrum Disorder Treatment

Therapy services provided by a licensed or certified speech therapist, occupational therapist or physical

therapist for the treatment of Autism Spectrum Disorders.

3. Cellular and Gene Therapy

Cellular Therapy and Gene Therapy received on an inpatient or outpatient basis at a Hospital or on an

outpatient basis at an Alternate Facility or in a Physician's office.

Benefits for CAR-T therapy for malignancies are provided as described under Transplantation Services.

4. Children's Early Intervention Services

Children's early intervention services are available for Enrolled Dependent children from birth to 36

months of age.

For purposes of this Benefit, "children's early intervention services" means services provided by licensed

occupational therapists, physical therapists, speech-language pathologists or clinical social workers

working with children with an identified developmental disability or delay as described under Part C of the

federal Individuals with Disabilities Education Act.

5. Clinical Trials

Routine patient care costs incurred while taking part 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 which is likely to cause death unless the course of the disease or

condition is interrupted.

• Cardiovascular disease (cardiac/stroke) which is not life threatening, when we determine the

clinical trial meets the qualifying clinical trial criteria stated below.

• Surgical musculoskeletal disorders of the spine, hip and knees, which are not life threatening, when

we determine the clinical trial meets the qualifying clinical trial criteria stated below.

• Other diseases or disorders which are not life threatening, when we determine the 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 taking part in a qualifying clinical trial.

Benefits are available only when you are clinically eligible, as determined by the researcher, to take part

in the qualifying clinical trial and when you meet the following conditions:

• You have a life-threatening illness for which no standard treatment is effective.

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• You are eligible to participate according to the clinical trial protocol with respect to treatment of

such illness.

• Your participation in the trial offers meaningful potential to you for significant clinical benefit.

• Your referring Physician has concluded that your participation in such a trial would be appropriate

based on the satisfaction of the above conditions.

Routine patient care costs for qualifying clinical trials include:

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

• Covered Health Care Services required solely for the following:

▪ The provision of the Experimental or Investigational Service(s) or item.

▪ The clinically appropriate monitoring of the effects of the service or item, or

▪ The prevention of complications.

• Covered Health Care Services needed for reasonable and necessary care arising from the receipt

of an Experimental or Investigational Service(s) or item.

Routine costs for clinical trials do not include:

• The Experimental or Investigational Service(s) 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 meet data collection and analysis needs and that are not

used in the direct clinical management of the patient.

• A service that clearly does not meet 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 taking part 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. It takes place in relation to the prevention, detection or

treatment of cancer or other life-threatening disease or condition. It meets any of the following criteria in

the bulleted list below.

With respect to cardiovascular disease, 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. It takes place in relation to the detection or treatment of such non-life-threatening

disease or disorder. It 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) or a cooperative group or center of the NIH. (Includes

National Cancer Institute (NCI).)

▪ Federal Department of Health and Human Services (DHHS).

▪ Centers for Disease Control and Prevention (CDC).

▪ Agency for Healthcare Research and Quality (AHRQ).

▪ Centers for Medicare and Medicaid Services (CMS).

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▪ 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 if the study or investigation has been reviewed and approved through a system of

peer review. The peer review system 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 takes place 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. It must

have been approved by all relevant institutional review boards (IRBs) before you 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 Care Service and is not otherwise excluded under the Policy.

6. Congenital Heart Disease (CHD) Surgeries

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.

• Hypoplastic left or right heart syndrome.

Benefits 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.

You can call us at the telephone number on your ID card for information about our specific guidelines

regarding Benefits for CHD services.

7. Dental Anesthesia Services

General anesthesia and associated facility charges for dental procedures rendered in a Hospital for

certain Covered Persons when the clinical status or underlying medical condition requires dental

procedures that ordinarily would not require general anesthesia to be rendered in a Hospital.

This section applies only to Covered Persons who meet the following criteria:

• Covered Persons, including infants, exhibiting physical, intellectual or medically compromising

conditions for which dental treatment under local anesthesia, with or without additional adjunctive

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techniques and modalities, can be expected to provide a successful result and for which dental

treatment under general anesthesia can be expected to produce a superior result.

• Covered Persons demonstrating dental treatment needs for which local anesthesia is ineffective

because of acute infection, anatomic variation or allergy.

• Extremely uncooperative, fearful, anxious or uncommunicative children or adolescents with dental

needs of such magnitude that treatment should not be postponed or deferred and for whom lack of

treatment can be expected to result in dental or oral pain or infection, loss of teeth or other

increased oral or dental morbidity.

• Covered Persons who have sustained extensive oral-facial or dental trauma for which treatment

under local anesthesia would be ineffective or compromised.

8. Dental Services - Accident Only

Dental services when all of the following are true:

• Treatment is needed because of Accidental damage.

• You receive dental services from a Doctor of Dental Surgery, Doctor of Medical Dentistry or

licensed independent practice dental hygienist.

Please note that dental damage that happens as a result of normal activities of daily living or

extraordinary use of the teeth is not considered an Accidental Injury. 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 follow this time-frame:

• Treatment must be completed within 12 months of the Accident, or if not a Covered Person at the

time of the Accident, within the first 12 months of coverage under the Policy.

Benefits for treatment of Accidental Injury are limited to the following:

• Emergency exam.

• 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 Injury with implant, dentures or bridges.

When services are provided by an independent practice dental hygienist, such services are limited to

those provided within the scope of practice of the independent practice dental hygienist.

9. Diabetes Services

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

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

therapy services. Services must be ordered by a Physician and provided by appropriately licensed or

registered health care professionals including outpatient self-management training and education

services provided through ambulatory diabetes education facilities authorized by the Maine Diabetes

Control Project within the Maine Bureau of Health.

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Benefits also include medical eye exams (dilated retinal exams) and preventive foot care for diabetes and

systemic circulatory disease.

Diabetic Self-Management Items

Insulin pumps and supplies and continuous glucose monitors for the management and treatment of

diabetes, based upon your medical needs. An insulin pump is subject to all the conditions of coverage

stated under Durable Medical Equipment (DME), Orthotics and Supplies. Benefits for insulin, oral

hypoglycemic agents, blood glucose meters including continuous 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.

10.Durable Medical Equipment (DME), Orthotics and Supplies

Benefits are provided for DME and certain orthotics and supplies. If more than one item can meet your

functional needs, Benefits are available only for the item that meets the minimum specifications for your

needs. If you purchase an item that exceeds these minimum specifications, we will pay only the amount

that we would have paid for the item that meets the minimum specifications, and you will be responsible

for paying any difference in cost.

DME and Supplies

Examples of DME and supplies include:

▪ Equipment to help 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).

▪ Negative pressure wound therapy pumps (wound vacuums).

▪ Mechanical equipment needed for the treatment of long term or sudden 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 needed 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.

Benefits include lymphedema stockings for the arm as required by the Women's Health and

Cancer Rights Act of 1998.

Benefits also include dedicated speech generating devices and tracheo-esophageal voice devices

required for treatment of severe speech impairment or lack of speech directly due to Sickness or

Injury. Benefits for the purchase of these devices are available only after completing a required

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

Orthotics

Orthotic devices that support, correct or alleviate neuromuscular or musculoskeletal dysfunction,

disease, Injury or deformity, limited to custom fabricated, medically appropriate braces or supports.

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

Benefits are available for repairs and replacement, except as described in Section 2: Exclusions and

Limitations, under Medical Supplies and Equipment.

These Benefits apply to external DME. Unless otherwise excluded, items that are fully implanted into the

body are a Covered Health Care Service for which Benefits are available under the applicable

medical/surgical Covered Health Care Service categories in this Certificate.

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11.Emergency Health Care Services - Outpatient

Services that are required to stabilize or begin treatment in an Emergency. Emergency Health Care

Services must be received on an outpatient basis at a Hospital or Alternate Facility.

Benefits include the facility charge, supplies and all professional services required to stabilize your

condition and/or begin treatment. This includes placement in an observation bed to monitor your condition

(rather than being admitted to a Hospital for an Inpatient Stay).

12.Enteral Nutrition

Benefits are provided for enteral formulas and low protein modified food products, administered either

orally or by tube feeding as the primary source of nutrition, for certain conditions which require specialized

nutrients or formulas. Examples of conditions include:

• Metabolic diseases such as phenylketonuria (PKU) and maple syrup urine disease.

• Severe food allergies.

• Impaired absorption of nutrients caused by disorders affecting the gastrointestinal tract.

Benefits for prescription or over-the-counter formula and products are available when a Physician issues

a prescription or written order stating the formula or product is Medically Necessary for the therapeutic

treatment of a condition requiring specialized nutrients and specifying the quantity and the duration of the

prescription or order. The formula or product must be administered under the direction of a Physician or

registered dietitian.

For the purpose of this Benefit, "enteral formulas" include:

• Amino acid-based elemental formulas.

• Extensively hydrolyzed protein formulas.

• Modified nutrient content formulas.

For the purpose of this Benefit, "severe food allergies" mean allergies which if left untreated will result in:

• Malnourishment;

• Chronic physical disability;

• Intellectual disability; or

• Loss of life.

13.Family Planning

Family planning services and contraceptives approved by the Food and Drug Administration (FDA) to

prevent Pregnancy, including related consultations, examinations, procedures and medical services

provided on an outpatient basis.

14.Fertility Preservation for Iatrogenic Infertility

Benefits are available for fertility preservation for medical reasons that cause irreversible infertility such as

chemotherapy, radiation treatment, and bilateral oophorectomy due to cancer. Services include the

following procedures, when provided by or under the care or supervision of a Physician:

• Collection of sperm.

• Cryo-preservation of sperm.

• Ovarian stimulation, retrieval of eggs and fertilization.

• Oocyte cryo-preservation.

• Embryo cryo-preservation.

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Benefits for medications related to the treatment of fertility preservation are provided as described under

your Outpatient Prescription Drug Rider or under Pharmaceutical Products - Outpatient in this section.

Benefits are not available for embryo transfer.

Benefits are not available for long-term storage costs (greater than one year).

15.Gender Dysphoria

Benefits for the treatment of gender dysphoria provided by or under the direction of a Physician.

For the purpose of this Benefit, "gender dysphoria" is a disorder characterized by the specific diagnostic

criteria classified in the current edition of the Diagnostic and Statistical Manual of the American

Psychiatric Association.

16.Habilitative Services

For purposes of this Benefit, "habilitative services" means Skilled Care services that are part of a

prescribed treatment plan or maintenance program to help a person with a disabling condition to keep,

learn or improve skills and functioning for daily living. We will decide if Benefits are available by reviewing

both the skilled nature of the service and the need for Physician-directed medical management.

Therapies provided for the purpose of general well-being or conditioning in the absence of a disabling

condition are not considered habilitative services.

Habilitative services are limited to:

• Physical therapy.

• Occupational therapy.

• Manipulative Treatment.

• Speech therapy.

• Post-cochlear implant aural therapy.

• Cognitive therapy.

Benefits are provided for habilitative services for both inpatient services and outpatient therapy when you

have a disabling condition when both of the following conditions are met:

• Treatment is administered by any of the following:

▪ Licensed speech-language pathologist.

▪ Licensed audiologist.

▪ Licensed occupational therapist.

▪ Licensed physical therapist.

▪ Physician.

• Treatment must be proven and not Experimental or Investigational.

The following are not habilitative services:

• Custodial Care.

• Respite care.

• Day care.

• Therapeutic recreation.

• Vocational training.

• Residential Treatment.

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• A service that does not help you meet functional goals in a treatment plan within a prescribed time

frame.

• Services solely educational in nature.

• Educational services otherwise paid under state or federal law.

We may require the following be provided:

• Treatment plan.

• Medical records.

• Clinical notes.

• Other necessary data to allow us to prove that medical treatment is needed.

When the treating provider expects that continued treatment is or will be required to allow you to achieve

progress that is capable of being demonstrated, we may request a treatment plan that includes:

• Diagnosis.

• Proposed treatment by type, frequency, and expected duration of treatment.

• Expected treatment goals.

• Frequency of treatment plan updates.

Habilitative services provided in your home by a Home Health Agency are provided as described under

Home Health Care. Habilitative services provided in your home other than by a Home Health Agency are

provided as described under this section.

Benefits for DME and prosthetic devices, when used as a part of habilitative services, are described

under Durable Medical Equipment (DME), Orthotics and Supplies and Prosthetic Devices.

Habilitative services performed as part of a certified early intervention services program as stated under

Children's Early Intervention Services are not subject to the annual visit limits as stated in the Schedule of

Benefits under either Rehabilitation Services - Outpatient Therapy or under Therapeutic, Adjustive and

Manipulative Services.

Habilitative services performed as stated under Autism Spectrum Disorder Treatment or under Mental

Health Care and Substance-Related and Addictive Disorders Services are not subject to the annual visit

limits as stated in the Schedule of Benefits under either Rehabilitation Services - Outpatient Therapy or

under Therapeutic, Adjustive and Manipulative Services.

17.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). These are electronic amplifying devices

designed to bring sound more effectively into the ear. These consist of a microphone, amplifier and

receiver.

Benefits are available for a hearing aid that is purchased due to a written recommendation by a Physician

or state licensed audiologist. Benefits are provided for the hearing aid for each hearing-impaired ear and

associated fitting charges and testing.

If more than one type of hearing aid can meet your functional needs, Benefits are available only for the

hearing aid that meets the minimum specifications for your needs. If you purchase a hearing aid that

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

hearing aid that meets the minimum specifications, and you will be responsible for paying any difference

in cost.

The hearing aid must be purchased in accordance with federal and state laws, regulations and rules for

the sale and dispensing of hearing aids.

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Benefits do not include bone anchored hearing aids. Bone anchored hearing aids are a Covered Health

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

Services categories in this Certificate. They are only available if you have either of the following:

• Craniofacial anomalies whose abnormal or absent ear canals prevent the use of a wearable

hearing aid.

• Hearing loss severe enough that it would not be remedied by a wearable hearing aid.

18.Home Health Care

Services received from a Home Health Agency that are all 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.

• Provided on a part-time, Intermittent Care schedule.

• Provided when Skilled Care is required.

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

for Physician-directed medical management.

Home health care visits include the following:

• Visits by a registered Nurse or licensed practical Nurse to carry out treatments prescribed, or

supporting nursing care and observation as indicated.

• A Physician's home or office visits or both.

• Visits by a registered physical, speech, occupational, inhalation or dietary therapist for services or

for evaluation of, consultation with and instruction of Nurses in carrying out such therapy prescribed

by the attending Physician, or both.

• Any prescribed lab tests and x-ray examinations using Hospital or community facilities, drugs,

dressings, oxygen or medical appliances and equipment as prescribed by a Physician, but only to

the extent that such charges would have been covered if you had remained in the Hospital.

• Visits by persons who have completed a home health aide training course under the supervision of

a registered Nurse for the purpose of giving personal care to the patient and performing light

household tasks as required by the plan of care, but not including services.

There is no requirement that hospitalization be an antecedent to Benefits under this section.

19.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 who have a prognosis of 12 months or less. It includes

the following:

• Physical, psychological, social, spiritual and respite care for the terminally ill person.

• Short-term grief counseling for immediate family members while you are receiving hospice care.

Benefits are available when you receive hospice care from a licensed hospice agency.

Hospice care services must be provided according to a written care delivery plan developed by a hospice

care provider and the recipient of the hospice care services. Benefits are available for hospice care

services whether the services are provided in a home setting or an inpatient setting (either at an acute

care Hospital or Skilled Nursing Facility). Hospice care services include, but are not limited to the

following:

• Physician services.

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• Nursing care.

• Respite care.

• Medical and social work services.

• Counseling services.

• Nutritional counseling.

• Pain and symptom management.

• Medical supplies and Durable Medical Equipment (DME).

• Occupational, physical or speech therapies.

• Volunteer services.

• Home health care services.

• Bereavement services.

Coverage for hospice respite care includes Benefits for up to a 48-hour period. Respite care is intended

to allow the person who regularly assists the patient at home, either a family member or other non-

professional, to have personal time solely for relaxation. The patient may then need a temporary

replacement to provide hospice care.

You can call us at the telephone number on your ID card for information about our guidelines for hospice

care.

20.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). This Benefit includes

general nursing care, special duty nursing and special diets.

• Use of intensive care or coronary care unit; diagnostic services; medical, surgical and central

supplies; treatment services; Hospital ancillary services including but not limited to use of operating

room, anesthesia, laboratory, x-ray, occupational therapy, physical therapy, speech therapy,

inhalation therapy and radiotherapy services; Phase I Cardiac Rehabilitation.

• Medication used while you are an inpatient such as drugs, biologicals and vaccines. This does not

include the use of drugs for purposes not specified on their labels except for the following:

▪ The diagnosis of cancer, HIV or AIDS.

▪ As approved for Medically Necessary indications.

▪ As required by law.

Benefits are not provided for any investigational new drugs unless approved by us for

medically accepted indications or as required by law.

• Blood or blood derivatives.

• Newborn care, including routine well-baby care.

• Blood transfusions including the cost of blood, blood plasma and blood plasma expanders as well

as the administrative costs of autologous blood pre-donations.

• Medically appropriate inpatient coverage following a mastectomy, a lumpectomy or a lymph node

dissection for the treatment of breast cancer including breast reconstruction procedures for the

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period of time determined by the attending Physician in consultation with you. Breast reconstruction

Benefits are described under Reconstructive Procedures.

• 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.)

21.Infant Formula

Amino acid-based elemental infant formula for children two years of age and under without regard to the

method of delivery of the formula. Benefits will be provided when a licensed Physician has diagnosed,

and through medical evaluation has documented, one of the following conditions:

• Symptomatic allergic colitis or proctitis.

• Laboratory or biopsy-proven allergic or eosinophilic gastroenteritis.

• A history of anaphylaxis.

• Gastroesophageal reflux disease that is non-responsive to standard medical therapies.

• Severe vomiting or diarrhea resulting in clinically significant dehydration requiring medical

treatment.

• Cystic fibrosis.

• Malabsorption of cow milk-based or soy milk-based infant formula.

In addition to meeting the conditions stated in the definition of Medically Necessary in Section 9: Defined

Terms, amino acid-based elemental infant formula will be considered Medically Necessary when the

following conditions are met:

• The amino acid-based elemental infant formula is the predominant source of nutritional intake at a

rate of 50% or greater; and

• Other commercial infant formulas including cow milk-based and soy milk-based formulas have

been tried and failed or are contraindicated.

We may require that a licensed Physician confirm and document ongoing Medical Necessity at least once

a year.

22.Lab, X-Ray and Diagnostic - Outpatient

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

Hospital or Alternate Facility, freestanding imaging center, independent laboratory or in a Physician's

office include:

• Lab, including human leukocyte antigen testing performed to establish bone marrow transplantation

suitability, a prostate-specific antigen test to screen for prostate cancer and radiology/X-ray.

• Mammography. A screening mammogram also includes an additional radiologic procedure

recommended by a provider when the results of an initial radiologic procedure are not definitive.

Benefits 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.)

• Genetic Testing ordered by a Physician which results in available medical treatment options

following Genetic Counseling.

• Presumptive Drug Tests and Definitive Drug Tests.

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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

Major Diagnostic and Imaging - Outpatient.

23.Major Diagnostic and Imaging - 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 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.)

24.Medical Foods

Metabolic formula and special modified low-protein food products that have been prescribed by a licensed

Physician for a person with an inborn error of metabolism.

As used in this section, "inborn error of metabolism" means a genetically determined biochemical disorder

in which a specific enzyme defect produces a metabolic block that may have pathogenic consequences

at birth or later in life. As used in this section, "special modified low-protein food product" means food

formulated to reduce the protein content to less than one gram of protein per serving and does not

include foods naturally low in protein.

25.Mental Health Care and Substance-Related and Addictive Disorders Services

Mental Health Care and Substance-Related and Addictive Disorders Services include those received on

an inpatient or outpatient basis in a Hospital, an Alternate Facility or in a provider's office. All services

must be provided by or under the direction of a behavioral health provider who is properly licensed and

qualified by law and acting within the scope of their licensure.

Benefits include Mental Health Care Services for the treatment of Biologically-based Mental Illness,

including psychotic disorders, including schizophrenia, dissociative disorders, mood disorders, anxiety

disorders, personality disorders, paraphilias, attention deficit and disruptive behavior disorders, tic

disorders, and eating disorders (including bulimia and anorexia). We may not deny treatment for Mental

Health Care Services that use “evidence-based practices” and are determined to be Medically Necessary

health care for a Dependent 21 years of age or younger. "Evidence-based practices" means clinically

sound and scientifically based policies, practices and programs that reflect expert consensus on the

prevention, treatment and recovery science, including, but not limited to, policies, practices and programs

published and disseminated by the Substance Abuse and Mental Health Services Administration and the

Title IV-E Prevention Services Clearinghouse within the United States Department of Health and Human

Services, the What Works Clearinghouse within the United States Department of Education, Institute of

Education Sciences and the California Evidence-Based Clearinghouse for Child Welfare within the

California Department of Social Services, Office of Child Abuse Prevention.

Benefits for Substance-Related and Addictive Disorders Services include care rendered by a state-

licensed, approved or certified detoxification, Residential Treatment program, or partial hospitalization

program on a periodic basis, including, but not limited to, patient diagnosis, assessment and treatment,

individual, family and group counseling and educational and support services.

Benefits include the following levels of care:

• Inpatient treatment including a range of physiological, psychological and other intervention

concepts, techniques and processes in a community mental health psychiatric inpatient unit,

general Hospital psychiatric unit or psychiatric Hospital licensed by the Department of Human

Services or an accredited public Hospital to restore psychosocial functioning sufficient to allow

maintenance and support of the client in a less restrictive setting.

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• Residential Treatment at a facility that provides care 24 hours daily to one or more patients. The

term Residential Treatment includes, but is not limited to the following services: room and board;

medical, nursing and dietary services; patient diagnosis, assessment and treatment; individual,

family and group counseling; and educational and support services, including a designated unit of a

licensed health care facility providing any and all other services specified in this paragraph to

patient with the illness of alcoholism and drug dependency.

• Partial Hospitalization/Day Treatment.

• Intensive Outpatient Treatment.

• Outpatient treatment including screening, evaluation, consultations, diagnosis and treatment

involving use of psychoeducational, physiological, psychological and psychosocial evaluative and

interventive concepts, techniques and processes provided to individuals and groups.

• Outpatient Benefits are also available for home health care services which means those services

rendered by a licensed provider of Mental Health Care Services to provide Medically Necessary

Benefits to a person suffering from a Mental Illness in the person's place of residence if:

▪ Hospitalization or confinement in a Residential Treatment Facility would otherwise have

been required if home health care services were not provided.

▪ The services are prescribed in writing by a licensed allopathic or osteopathic Physician or a

licensed psychologist who is trained and has received a doctorate in psychology specializing

in the evaluation and treatment of Mental Illness.

There is no requirement that hospitalization or confinement in a Residential Treatment Facility be

an antecedent to home health care services.

Inpatient treatment and Residential Treatment includes room and board in a Semi-private Room (a room

with two or more beds).

Services include the following:

• Diagnostic evaluations, assessment and treatment planning.

• Treatment and/or procedures.

• Medication management and other associated treatments.

• Individual, family, and group therapy.

• Crisis intervention.

• Detoxification.

• Mental Health Care Services for Autism Spectrum Disorder (including Intensive Behavioral

Therapies such as Applied Behavior Analysis (ABA)) or other professional counseling services

necessary to develop, maintain and restore the functioning of an individual to the extent possible

that are the following:

▪ Focused on the treatment of core deficits of Autism Spectrum Disorder.

▪ Provided by a Board Certified Behavior Analyst (BCBA) or other qualified provider under the

appropriate supervision.

▪ Focused on treating maladaptive/stereotypic behaviors that are posing danger to self, others

and property, and impairment in daily functioning.

ABA means the design, implementation and evaluation of environmental modification using

behavioral stimuli and consequences to produce socially significant improvement in human

behavior, including the use of direct observation, measurement and functional analysis of the

relations between environment and behavior. In order to be eligible for Benefits, ABA must be

provided by a person professionally certified by a national board of behavior analysts or performed

under the supervision of a person professionally certified by a national board of behavior analysts.

COC23.INS.2018.SG.ME

Benefits for therapy services provided by a licensed or certified speech therapist, occupational

therapist or physical therapist are described under Autism Spectrum Disorder Treatment.

This section describes only the behavioral component of treatment for Autism Spectrum Disorder.

Medical treatment of Autism Spectrum Disorder is a Covered Health Care Service for which

Benefits are available under the applicable medical Covered Health Care Services categories in

this Certificate.

• Counseling services related to Autism Spectrum Disorder provided by a licensed psychiatrist,

psychologist, clinical professional counselor or clinical social worker.

The Mental Health/Substance-Related and Addictive Disorders Designee provides administrative services

for all levels of care.

We encourage you to contact the Mental Health/Substance-Related and Addictive Disorders Designee for

assistance in locating a provider and coordination of care.

26.Obesity - Weight Loss Surgery

Surgical treatment of obesity when provided by or under the direction of a Physician when you have been

diagnosed as morbidly obese for a minimum of five consecutive years. Benefits are limited to surgery for

an intestinal bypass, gastric bypass or gastroplasty.

27.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.

28.Parenteral and Enteral Therapy

Supplies and equipment needed to appropriately administer parenteral and enteral therapy. Benefits are

not available for nutritional supplements for the sole purpose of enhancing dietary intake unless they are

given in conjunction with enteral therapy.

29.Pharmaceutical Products - Outpatient

Pharmaceutical Products for Covered Health Care Services administered on an outpatient basis in a

Hospital, Alternate Facility, Physician's office, or in your home.

Benefits are provided for Pharmaceutical Products which, due to their traits (as determined by us), are

administered or directly supervised by a qualified provider or licensed/certified health professional.

Depending on where the Pharmaceutical Product is administered, Benefits will be provided for

administration of the Pharmaceutical Product under the corresponding Benefit category in this Certificate.

Benefits for medication normally available by a prescription or order or refill are provided as described

under your Outpatient Prescription Drug Rider.

If you require certain Pharmaceutical Products, including Specialty Pharmaceutical Products, we may

direct you to a Designated Dispensing Entity. Such Designated Dispensing Entities may include an

outpatient pharmacy, specialty pharmacy, Home Health Agency provider, Hospital-affiliated pharmacy or

hemophilia treatment center contracted pharmacy.

If you/your provider are directed to a Designated Dispensing Entity and you/your provider choose not to

get your Pharmaceutical Product from a Designated Dispensing Entity, Network Benefits are not available

for that Pharmaceutical Product.

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Certain Pharmaceutical Products are subject to step therapy requirements. This means that in order to

receive Benefits for such Pharmaceutical Products, you must use a different Pharmaceutical Product

and/or prescription drug product first. You may find out whether a particular Pharmaceutical Product is

subject to step therapy requirements by contacting us at www.myuhc.com or the telephone number on

your ID card.

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 by contacting us at

www.myuhc.com or the telephone number on your ID card.

30.Physician Fees for Surgical and Medical Services

Physician fees for surgical procedures and other medical services received on an outpatient or inpatient

basis in a Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility or Alternate Facility, or for

Physician house calls.

31.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 regardless of whether the Physician's office is freestanding, located in a clinic or located in a

Hospital.

Covered Health Care Services include services at a retail health clinic, which are limited to basic health

care services on a "walk-in" basis. These clinics are normally found in major pharmacies or retail stores.

Health care services are typically given by a Physician's assistant or Nurse practitioner and are limited to

routine care and treatment to common illnesses for adults and children.

Covered Health Care Services include medical education services that are provided in a Physician's

office by appropriately licensed or registered health care professionals when both of the following are

true:

• Education is required for a disease in which patient self-management is a part of treatment.

• There is a lack of knowledge regarding the disease which requires the help of a trained health

professional.

Covered Health Care Services include Genetic Counseling.

Benefits under this section include, but are not limited to the following:

• Allergy testing and injections.

• Removal of sutures, application or removal of a cast or removal of impacted or un-erupted teeth.

• Digital rectal examinations to screen for prostate cancer.

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

Preventive Care Services.

Benefits for CT scans, PET scans, MRI, MRA, nuclear medicine and major diagnostic services are

described under Major Diagnostic and Imaging - Outpatient.

When a test is performed or a sample is drawn in the Physician's office, Benefits for the analysis or

testing of a lab, radiology/X-ray or other diagnostic service, whether performed in or out of the Physician's

office, are described under Lab, X-ray and Diagnostic - Outpatient.

32.Pregnancy - Maternity Services

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

delivery and any related complications.

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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 Care Services include related tests and treatment.

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.

Benefits will be provided for postpartum care services for 12 months following childbirth. Coverage will

meet the standards of the American College of Obstetricians and Gynecologists, as outlined in the

“Optimizing Postpartum Care” opinion published May 2018. Coverage will include:

• A postpartum care plan.

• Contact with Covered Person within 3 weeks of end of pregnancy.

• A comprehensive postpartum visit.

• Treatment of complications of pregnancy and childbirth.

• Assessment of risk factors for cardiovascular disease.

• Care related to pregnancy loss.

33.Preimplantation Genetic Testing (PGT) and Related Services

Preimplantation Genetic Testing (PGT) performed to identify and to prevent genetic medical conditions

from being passed onto offspring. To be eligible for Benefits the following must be met:

• PGT must be ordered by a Physician after Genetic Counseling.

• The genetic medical condition, if passed onto offspring, would result in significant health problems

or severe disability and be caused by a single gene (detectable by PGT-M) or structural changes of

a parents’ chromosome (detectable by PGT-SR).

• Benefits are limited to PGT for the specific genetic disorder and the following related services when

provided by or under the supervision of a Physician:

▪ Ovulation induction (or controlled ovarian stimulation).

▪ Egg retrieval, fertilization and embryo culture.

▪ Embryo biopsy.

▪ Embryo transfer.

▪ Cryo-preservation and short-term embryo storage (less than one year).

Benefits are not available for long-term storage costs (greater than one year).

34.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.

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• 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.

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

comprehensive guidelines supported by the Health Resources and Services Administration.

Benefits defined under the Health Resources and Services Administration (HRSA) requirement

include one breast pump per Pregnancy in conjunction with childbirth. Breast pumps must be

ordered by or provided by a Physician. You can find more information on how to access Benefits

for breast pumps by contacting us at www.myuhc.com or the telephone number on your ID card.

If more than one breast pump can meet your needs, Benefits are available only for the most cost

effective pump. We will determine the following:

▪ Which pump is the most cost effective.

▪ Whether the pump should be purchased or rented (and the duration of any rental).

▪ Timing of purchase or rental.

Benefits defined under the Health Resources and Services Administration (HRSA) requirement

include screening for cervical cancer.

35.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. Benefits for lymphedema stockings for the arm are provided as

described under Durable Medical Equipment (DME), Orthotics and Supplies.

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

implanted into the body. Internal prosthetics are a Covered Health Care Service for which Benefits are

available under the applicable medical/surgical Covered Health Care Service categories in this

Certificate.

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 as described in Section 2: Exclusions and

Limitations, under Devices, Appliances and Prosthetics.

36.Reconstructive Procedures

Reconstructive procedures when the primary purpose of the procedure is either of the following:

• Treatment of a medical condition.

• Improvement or restoration of physiologic function.

• Necessary to correct a birth defect for a Covered Dependent child who has a functional physical

deficit due to the birth defect.

COC23.INS.2018.SG.ME

Reconstructive procedures include surgery or other procedures which are related to an Injury, Sickness

or Congenital Anomaly and include Medically Necessary breast reduction surgery and symptomatic

varicose vein surgery. 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 you 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 Care Service. You can call us at the telephone number on your ID card for more information about

Benefits for mastectomy-related services.

37.Rehabilitation Services - Outpatient Therapy

Short-term outpatient rehabilitation services limited to:

• Physical therapy.

• Occupational therapy.

• Speech therapy.

• Pulmonary rehabilitation therapy.

• Cardiac rehabilitation therapy.

• Post-cochlear implant aural therapy.

• Cognitive rehabilitation therapy.

• Massage therapy when part of an active course of treatment and performed by an eligible provider.

Massage therapists are not considered eligible providers.

• Inhalation therapy.

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

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

Alternate Facility. Rehabilitative services provided in your home by a Home Health Agency are provided

as described under Home Health Care. Rehabilitative services provided in your home other than by a

Home Health Agency are provided as described under this section.

Benefits can be denied or shortened when either of the following applies:

• You are not progressing in goal-directed rehabilitation services.

• Rehabilitation goals have previously been met.

Benefits are not available for maintenance/preventive treatment.

For outpatient rehabilitative services for speech therapy we will pay Benefits 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. We will pay Benefits for cognitive rehabilitation therapy only

when Medically Necessary following a post-traumatic brain Injury or stroke.

38.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.

COC23.INS.2018.SG.ME

Diagnostic scopic procedures are those for visualization, biopsy and polyp removal, except for those

services described under Preventive Care Services. Examples of diagnostic scopic procedures include:

• Colonoscopy.

• Sigmoidoscopy.

• Diagnostic endoscopy.

• Colorectal cancer screenings for asymptomatic individuals who are:

▪ At average risk for colorectal cancer according to the most recently published colorectal

cancer screening guidelines of a national cancer society; or

▪ At high risk for colorectal cancer.

Colorectal cancer screening means all colorectal cancer examinations and laboratory tests

recommended by a health care provider in accordance with the most recently published colorectal

cancer screening guidelines of a national cancer society.

If a colonoscopy is recommended as the colorectal cancer screening and a lesion is discovered

and removed during the colonoscopy Benefits will be paid for the screening colonoscopy as the

primary procedure.

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

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

Benefits 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.)

Benefits that apply to certain preventive screenings are described under Preventive Care Services.

39.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 first confinement in a Skilled Nursing Facility or Inpatient Rehabilitation Facility was or will be

a cost effective option to an Inpatient Stay in a Hospital.

• You will receive Skilled Care services that are not primarily 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.

Benefits can be denied or shortened when either of the following applies:

• You are not progressing in goal-directed rehabilitation services.

• Discharge rehabilitation goals have previously been met.

40.Smoking Cessation

COC23.INS.2018.SG.ME

Smoking cessation programs including both educational and medical treatments to help a person

overcome nicotine addiction. Qualifying programs must be recommended by a Physician who follows the

United States Public Health Service guidelines. Benefits under this section include nicotine replacement

therapy (NRT), including nicotine patches, gum or nasal spray.

41.Surgery - Outpatient

Surgery and related services received on an outpatient basis at a Hospital, Alternate Facility, Rural Health

Center or in a Physician's office.

Benefits include certain scopic procedures. Examples of surgical scopic procedures include:

• Arthroscopy.

• Laparoscopy.

• Bronchoscopy.

• Hysteroscopy.

Examples of surgical procedures performed in a Physician's office are mole removal, ear wax removal,

and cast application.

Benefits 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.)

• Blood administration.

• Blood transfusions including the cost of blood, blood plasma, and blood plasma expanders, and the

administrative costs of autologous blood pre-donations.

42.Therapeutic, Adjustive and Manipulative Services

Therapeutic, Adjustive and Manipulative Services when performed by a Network chiropractic, allopathic

or osteopathic doctor in the provider's office. Benefits include diagnosis and related services and are

limited to one visit and treatment per day.

Benefits include self-referral services under the following conditions:

• You may utilize the services of a Network Therapeutic, Adjustive and Manipulative Services

provider for 3 weeks or a maximum of 12 visits, whichever occurs first, of acute care treatment

without the prior approval of a Network Primary Care Physician. For purposes of this subsection,

"acute care treatment" means treatment for accidental bodily injury or sudden, severe pain that

affects the ability of the enrollee to engage in the normal activities, duties or responsibilities of daily

living.

• Within 3 working days of the first consultation, the Network Therapeutic, Adjustive and Manipulative

Services provider shall send to the Primary Care Physician a report containing the complaint,

related history, examination, initial diagnosis and treatment plan. If the Therapeutic, Adjustive and

Manipulative Services provider fails to send a report to the Primary Care Physician within 3 working

days, we are not obligated to provide benefits for Therapeutic, Adjustive and Manipulative Services

care and you is not liable to the Therapeutic, Adjustive and Manipulative Services provider for any

unpaid fees.

• If you and the Network Therapeutic, Adjustive and Manipulative Services provider determine that

your condition has not improved after 3 weeks of treatment or a maximum of 12 visits the Network

Therapeutic, Adjustive and Manipulative Services provider shall discontinue treatment and refer

you to your Primary Care Physician.

COC23.INS.2018.SG.ME

• If the Therapeutic, Adjustive and Manipulative Services provider recommends treatment beyond 3

weeks or a maximum of 12 visits, the Network Therapeutic, Adjustive and Manipulative Services

provider shall send to your Primary Care Physician a report containing information your progress

and outlining a treatment plan for extended Therapeutic, Adjustive and Manipulative Services care

of up to 5 more weeks or a maximum of 12 more visits, whichever occurs first.

• Without the approval of your Primary Care Physician, you may not receive benefits for more than

36 visits to a Network Therapeutic, Adjustive and Manipulative Services provider in a 12-month

period. After a maximum of 36 visits, your continuing Therapeutic, Adjustive and Manipulative

Services treatment must be authorized by the Primary Care Physician.

43.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 (which also may be rendered at

home).

• Radiation oncology.

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

basis at a Hospital or Alternate Facility by appropriately licensed or registered health care professionals

when both of the following are true:

• Education is required for a disease in which patient self-management is a part of treatment.

• There is a lack of knowledge regarding the disease which requires the help of a trained health

professional.

Benefits 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.

44.Transplantation Services

Organ and tissue transplants, including CAR-T cell therapy for malignancies, when ordered by a

Physician. Benefits are available for transplants when the transplant meets the definition of a Covered

Health Care Service, and is not an Experimental or Investigational or Unproven Service.

Examples of transplants for which Benefits are available include:

• Bone marrow, including CAR-T cell therapy for malignancies, allogeneic bone marrow, autologous

bone marrow. Bone marrow transplants that are not a Covered Health Care Service are those that

are specifically excluded in Section 2: Exclusions and Limitations, or those that meet the definition

of Experimental or Investigational or Unproven Service in Section 9: Defined Terms.

• Heart.

• Heart/lung.

• Lung.

• Islet tissue.

• Kidney.

• Kidney/pancreas.

• Liver.

COC23.INS.2018.SG.ME

• Liver/small intestine.

• Adrenal gland, cartilage, muscle, skin and tendon.

• Heart valve.

• Pancreas.

• Small intestine.

• Cornea.

• Blood vessel.

• Parathyroid.

Donor costs related to transplantation are Covered Health Care Services and are payable through the

organ recipient's coverage under the Policy, limited to donor:

• Identification.

• Evaluation.

• Organ removal.

• Direct follow-up care.

You can call us at the telephone number on your ID card for information about our specific guidelines

regarding Benefits for transplant services.

45.Urgent Care Center Services

Covered Health Care 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.

46.Urinary Catheters

Benefits for external, indwelling, and intermittent urinary catheters for incontinence or retention.

Benefits include related urologic supplies for indwelling catheters limited to:

• Urinary drainage bag and insertion tray (kit).

• Anchoring device.

• Irrigation tubing set.

47.Virtual Care Services

Virtual care for Covered Health Care Services that includes the diagnosis and treatment of less serious

medical conditions. Virtual care provides communication of medical information in real-time between the

patient and a distant Physician or health specialist, outside of a medical facility (for example, from home

or from work).

Network Benefits are available only when services are delivered through a Designated Virtual Network

Provider. You can find a Designated Virtual Network Provider by contacting us at www.myuhc.com or the

telephone number on your ID card.

Benefits are available for urgent, on-demand health care delivered through live audio or video

conferencing or audio only technology for treatment of acute but non-emergency medical needs.

Please Note: Not all medical conditions can be treated through virtual care. The Designated Virtual

Network Provider will identify any condition for which treatment by in-person Physician contact is needed.

COC23.INS.2018.SG.ME

Benefits do not include email or fax, or for services that occur within medical facilities (CMS defined

originating facilities).

48.Vision Correction After Surgery or Accident

Prescription, fitting or purchase of glasses or contact lenses for vision correction after surgery or Accident.

Coverage is provided as necessary to treat accommodative strabismus, cataracts, or aphakia.

COC23.INS.2018.SG.ME

Section 2: Exclusions and Limitations

How Do We Use Headings in this Section?

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

headings group services, treatments, items, or supplies that fall into a similar category. Exclusions appear

under the headings. A heading does not create, define, change, 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 Care Services,

except as may be specifically provided for in Section 1: Covered Health Care Services or through a Rider

to the Policy.

Where Are Benefit Limitations Shown?

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

1: Covered Health Care Services, those limits are stated in the corresponding Covered Health Care

Service category in the Schedule of Benefits. Limits may also apply to some Covered Health Care

Services that fall under more than one Covered Health Care Service category. When this occurs, those

limits are also stated in the Schedule of Benefits table. 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 except when part of an active course of treatment and performed by an eligible

provider as described under Rehabilitation Services - Outpatient Therapy in Section 1: Covered

Health Care Services.

5. Rolfing.

6. Wilderness, adventure, camping, outdoor, or other similar programs.

7. Art therapy, music therapy, dance therapy, animal-assisted therapy, and other forms of alternative

treatment as defined by the National Center for Complementary and Integrative Health (NCCIH) of

the National Institutes of Health. This exclusion does not apply to Therapeutic, Adjustive and

Manipulative Services and non-manipulative osteopathic care for which Benefits are provided as

described in Section 1: Covered Health Care Services.

B. Dental

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

including hospitalizations and anesthesia).

COC23.INS.2018.SG.ME

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

as described under Dental Services - Accident Only in Section 1: Covered Health Care Services or

under Dental Anesthesia Services in Section 1: Covered Health Care Services.

This exclusion does not apply to dental care (oral exam, 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 tooth decay or

cavities 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:

▪ Removal, restoration and replacement of teeth.

▪ Medical or surgical treatments of dental conditions.

▪ Services to improve dental clinical outcomes.

This exclusion does not apply to preventive care for which Benefits are provided under the United

States Preventive Services Task Force requirement or the Health Resources and Services

Administration (HRSA) requirement. This exclusion also does not apply to Accident-related dental

services for which Benefits are provided as described under Dental Services - Accident Only in

Section 1: Covered Health Care 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 in Section 1: Covered Health Care Services.

4. Dental braces (orthodontics).

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

Congenital Anomaly.

C. Devices, Appliances and Prosthetics

1. Devices used as safety items or to help 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. This exclusion does not apply to

cranial molding helmets and cranial banding that meet clinical criteria. This exclusion does not

apply to braces for which Benefits are provided as described under Durable Medical Equipment

(DME), Orthotics and Supplies in Section 1: Covered Health Care Services.

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

▪ Blood pressure cuff/monitor.

▪ Enuresis alarm.

▪ Non-wearable external defibrillator.

▪ Trusses.

▪ Ultrasonic nebulizers.

COC23.INS.2018.SG.ME

4. Devices and computers to help in communication and speech except for dedicated speech

generating devices and tracheo-esophageal voice devices for which Benefits are provided as

described under Durable Medical Equipment (DME), Orthotics and Supplies in Section 1: Covered

Health Care Services.

5. Oral appliances for snoring.

6. Repair or replacement of prosthetic devices due to misuse, malicious damage or gross neglect or

to replace lost or stolen items.

7. Diagnostic or monitoring equipment purchased for home use, unless otherwise described as a

Covered Health Care Service.

8. Powered and non-powered exoskeleton devices.

D. Drugs

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

2. Self-administered or self-infused medications. This exclusion does not apply to medications which,

due to their traits (as determined by us), must typically be administered or directly supervised by a

qualified provider or licensed/certified health professional in an outpatient setting. This exclusion

does not apply to certain hemophilia treatment centers that are contracted with a specific

hemophilia treatment center fee schedule that allows medications used to treat bleeding disorders

to be dispensed directly to Covered Persons for self-administration.

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 used while in the Physician's office.

4. Over-the-counter drugs and treatments.

5. Growth hormone therapy.

6. Certain New Pharmaceutical Products and/or new dosage forms until the date as determined by us

or our designee, but no later than December 31st of the following calendar year.

This exclusion does not apply if you have a life-threatening Sickness or condition (one that is likely

to cause death within one year of the request for treatment). If you have a life-threatening Sickness

or condition, under such circumstances, Benefits may be available for the New Pharmaceutical

Product to the extent provided in Section 1: Covered Health Care Services.

7. A Pharmaceutical Product that contains (an) active ingredient(s) available in and therapeutically

equivalent (having essentially the same efficacy and adverse effect profile) to another covered

Pharmaceutical Product. Such determinations may be made up to six times during a calendar year.

8. A Pharmaceutical Product that contains (an) active ingredient(s) which is (are) a modified version

of and therapeutically equivalent (having essentially the same efficacy and adverse effect profile) to

another covered Pharmaceutical Product. Such determinations may be made up to six times during

a calendar year.

9. A Pharmaceutical Product with an approved biosimilar or a biosimilar and therapeutically

equivalent (having essentially the same efficacy and adverse effect profile) to another covered

Pharmaceutical Product. For the purpose of this exclusion a "biosimilar" is a biological

Pharmaceutical Product approved based on showing that it is highly similar to a reference product

(a biological Pharmaceutical Product) and has no clinically meaningful differences in terms of

safety and effectiveness from the reference product. Such determinations may be made up to six

times per calendar year.

10. Certain Pharmaceutical Products for which there are therapeutically equivalent (having essentially

the same efficacy and adverse effect profile) alternatives available, unless otherwise required by

law or approved by us. Such determinations may be made up to six times during a calendar year.

11. Certain Pharmaceutical Products that have not been prescribed by a Specialist.

COC23.INS.2018.SG.ME

12. Compounded drugs that contain certain bulk chemicals. Compounded drugs that are available as a

similar commercially available Pharmaceutical Product.

13. Off-label use of Pharmaceutical Products except for the diagnosis of cancer, HIV or AIDS.

E. 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 Investigational 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.

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

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

F. Foot Care

1. Routine foot care. Examples include:

▪ Cutting or removal of corns and calluses.

▪ Nail trimming, nail cutting, or nail debridement.

▪ Hygienic and preventive maintenance foot care including cleaning and soaking the feet and

applying skin creams in order to maintain skin tone.

This exclusion does not apply to preventive foot care due to conditions associated with metabolic,

neurologic, or peripheral vascular disease.

2. Treatment of flat feet.

3. Treatment of subluxation of the foot.

4. Shoes.

5. Shoe orthotics.

6. Shoe inserts.

7. Arch supports.

G. Gender Dysphoria

1. Cosmetic Procedures, including the following:

▪ Abdominoplasty.

▪ Blepharoplasty.

▪ Breast enlargement, including augmentation mammoplasty and breast implants.

▪ Body contouring, such as lipoplasty.

▪ Brow lift.

▪ Calf implants.

▪ Cheek, chin, and nose implants.

▪ Injection of fillers or neurotoxins.

▪ Face lift, forehead lift, or neck tightening.

▪ Facial bone remodeling for facial feminizations.

▪ Hair removal, except as part of a genital reconstruction procedure by a Physician for the

treatment of gender dysphoria.

COC23.INS.2018.SG.ME

▪ Hair transplantation.

▪ Lip augmentation.

▪ Lip reduction.

▪ Liposuction.

▪ Mastopexy.

▪ Pectoral implants for chest masculinization.

▪ Rhinoplasty.

▪ Skin resurfacing.

▪ Thyroid cartilage reduction; reduction thyroid chondroplasty; trachea shave (removal or

reduction of the Adam's apple).

▪ Voice modification surgery.

▪ Voice lessons and voice therapy.

H. Medical Supplies and Equipment

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

▪ Compression stockings.

▪ Ace bandages.

▪ Gauze and dressings.

This exclusion does not apply to:

▪ Disposable supplies necessary for the effective use of DME or prosthetic devices for which

Benefits are provided as described under Durable Medical Equipment (DME), Orthotics and

Supplies and Prosthetic Devices in Section 1: Covered Health Care Services. This exception

does not apply to supplies for the administration of medical food products.

▪ Diabetic supplies for which Benefits are provided as described under Diabetes Services in

Section 1: Covered Health Care Services.

▪ Ostomy supplies for which Benefits are provided as described under Ostomy Supplies in

Section 1: Covered Health Care Services.

▪ Urinary catheters and related urologic supplies for which Benefits are provided as described

under Urinary Catheters in Section 1: Covered Health Care Services.

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

(DME), Orthotics and Supplies in Section 1: Covered Health Care Services.

3. Prescribed or non-prescribed publicly available devices, software applications and/or monitors that

can be used for non-medical purposes.

4. Repair or replacement of DME or orthotics due to misuse, malicious damage or gross neglect or to

replace lost or stolen items.

I. Mental Health Care and Substance-Related and Addictive Disorders

In addition to all other exclusions listed in this Section 2: Exclusions and Limitations, the exclusions listed

directly below apply to services described under Mental Health Care and Substance-Related and

Addictive Disorders Services in Section 1: Covered Health Care Services.

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

International Classification of Diseases section on Mental and Behavioral Disorders or Diagnostic

and Statistical Manual of the American Psychiatric Association.

COC23.INS.2018.SG.ME

2. Outside of an assessment, services as treatments for a primary diagnosis of conditions and

problems that may be a focus of clinical attention, but are specifically noted not to be mental

disorders within the current edition of the Diagnostic and Statistical Manual of the American

Psychiatric Association.

3. Outside of an assessment, services as treatments for the primary diagnoses of learning disabilities,

gambling disorder, and paraphilic disorders.

4. Services that are solely educational in nature or otherwise paid under state or federal law for purely

educational purposes.

5. Tuition or services that are school-based for children and adolescents required to be provided by,

or paid for by, the school under the Individuals with Disabilities Education Act.

6. Outside of an assessment, unspecified disorders for which the provider is not obligated to provide

clinical rationale as defined in the current edition of the Diagnostic and Statistical Manual of the

American Psychiatric Association.

7. Transitional Living services.

8. Non-Medical 24-Hour Withdrawal Management.

9. High intensity residential care, including American Society of Addiction Medicine (ASAM) Criteria,

for Covered Persons with substance-related and addictive disorders who are unable to participate

in their care due to significant cognitive impairment.

J. Nutrition

1. Individual and group nutritional counseling, except as described under Diabetes Services and

under Hospice Care in Section 1: Covered Health Care Services, including non-specific disease

nutritional education such as general good eating habits, calorie control or dietary preferences.

This exclusion does not apply to preventive care for which Benefits are provided under the United

States Preventive Services Task Force requirement. This exclusion also does not apply to medical

or behavioral/mental health related nutritional education services that are provided as part of

treatment for a disease 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 a part of

treatment.

▪ There is a lack of knowledge regarding the disease which requires the help of a trained

health professional.

2. Food of any kind, infant formula, standard milk-based formula, and donor breast milk. This

exclusion does not apply to enteral formula and other modified food products for which Benefits are

provided as described under Enteral Nutrition and under Medical Foods and under Infant Formula

in Section 1: Covered Health Care Services.

3. Nutritional or cosmetic therapy using high dose or mega quantities of vitamins, minerals or

elements and other nutrition-based therapy. Examples include supplements and electrolytes.

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:

COC23.INS.2018.SG.ME

▪ Air conditioners, air purifiers and filters and dehumidifiers.

▪ Batteries and battery chargers.

▪ Breast pumps. This exclusion does not apply to breast pumps for which Benefits are

provided under the Health Resources and Services Administration (HRSA) requirement.

▪ Car seats.

▪ Chairs, bath chairs, feeding chairs, toddler chairs, chair lifts and recliners.

▪ Exercise equipment.

▪ Home modifications such as elevators, handrails and ramps.

▪ Hot and cold compresses.

▪ 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.

▪ 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. This exclusion does not apply to liposuction for which

Benefits are provided as described under Reconstructive Procedures in Section 1: Covered

Health Care Services.

COC23.INS.2018.SG.ME

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

▪ Treatment for spider veins.

▪ Sclerotherapy treatment of veins.

▪ Hair removal or replacement by any means, except for hair removal as part of genital

reconstruction prescribed by a Physician for the treatment of gender dysphoria.

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 first breast implant followed mastectomy. See Reconstructive Procedures in Section 1:

Covered Health Care Services.

3. Treatment of benign gynecomastia (abnormal breast enlargement in males).

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

flexibility.

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. Removal of hanging skin on any part of the body. Examples include plastic surgery procedures

called abdominoplasty 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 to improve general physical conditions that are provided to reduce potential

risk factors, where improvement is not expected, including routine, long-term or

maintenance/preventive treatment.

5. Rehabilitation services for speech therapy except as required for treatment of a speech impairment

or speech dysfunction that results from Injury, stroke, cancer, or Congenital Anomaly.

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

traumatic brain Injury or stroke.

7. Physiological treatments and procedures that result in the same therapeutic effects when

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

8. Biofeedback.

9. Services for the evaluation and treatment of temporomandibular joint syndrome (TMJ), whether the

services are considered to be medical or dental in nature.

10. Upper and lower jawbone surgery, orthognathic surgery, and jaw alignment. This exclusion does

not apply to reconstructive jaw surgery required for you because of a Congenital Anomaly, acute

traumatic Injury, dislocation, tumors, cancer or obstructive sleep apnea.

11. Surgical treatment of obesity unless it is deemed to be Medically Necessary. Non-surgical

treatment of obesity.

12. Stand-alone multi-disciplinary tobacco cessation programs. These are programs that usually

include health care providers specializing in tobacco cessation and may include a psychologist,

social worker or other licensed or certified professionals. The programs usually include intensive

psychological support, behavior modification techniques and medications to control cravings. This

exclusion does not apply to the Benefits described under Smoking Cessation in Section 1: Covered

Health Care Services.

COC23.INS.2018.SG.ME

13. 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 Care Services and for those surgeries determined to be Medically Necessary.

14. Helicobacter pylori (H. pylori) serologic testing.

15. Intracellular micronutrient testing.

16. Cellular and Gene Therapy services not received from a Designated Provider.

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 address.

3. Services provided at a Freestanding Facility or diagnostic Hospital-based Facility without an order

written by a Physician or other provider. Services which are self-directed to a Freestanding Facility

or diagnostic Hospital-based Facility. Services ordered by a Physician or other provider who is an

employee or representative of a Freestanding Facility or diagnostic Hospital-based Facility, when

that Physician or other provider:

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

▪ Is not involved in your medical care after the service is received.

This exclusion does not apply to mammography.

O. Reproduction

1. Health care services and related expenses for infertility treatments, including assisted reproductive

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

described under Fertility Preservation for Iatrogenic Infertility and Preimplantation Genetic Testing

(PGT) and Related Services in Section 1: Covered Health Care Services.

2. The following services related to a Gestational Carrier or Surrogate:

▪ All costs related to reproductive techniques including:

♦ Assisted reproductive technology.

♦ Artificial insemination.

♦ Intrauterine insemination.

♦ Obtaining and transferring embryo(s).

♦ Preimplantation Genetic Testing (PGT) and related services.

▪ Health care services including:

♦ Inpatient or outpatient prenatal care and/or preventive care.

♦ Screenings and/or diagnostic testing.

♦ Delivery and post-natal care.

The exclusion for the health care services listed above does not apply when the Gestational

Carrier or Surrogate is a Covered Person.

▪ All fees including:

♦ Screening, hiring and compensation of a Gestational Carrier or Surrogate including

surrogacy agency fees.

COC23.INS.2018.SG.ME

♦ Surrogate insurance premiums.

♦ Travel or transportation fees.

3. Costs of donor eggs and donor sperm.

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

and ovarian tissue. This exclusion does not apply to short-term storage (less than one year) and

retrieval of reproductive materials for which Benefits are provided as described under Fertility

Preservation for Iatrogenic Infertility and Preimplantation Genetic Testing (PGT) and Related

Services in Section 1: Covered Health Care Services.

5. The reversal of voluntary sterilization.

6. In vitro fertilization regardless of the reason for treatment. This exclusion does not apply to in vitro

fertilization for which Benefits are provided as described under Preimplantation Genetic Testing

(PGT) and Related Services in Section 1: Covered Health Care Services.

P. Services Provided under another Plan

1. Health care services for when other coverage is required by federal, state or local law to be bought

or provided through other arrangements. Examples include coverage required by workers'

compensation, or similar legislation. However, coverage is provided for conditions that occurred at

work if the claim is controverted.

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. Services resulting from Accidental bodily injuries arising out of a motor vehicle Accident to the

extent the services are payable under a medical expense payment provision of an automobile

insurance policy.

3. Health care services for treatment of military service-related disabilities, when you are legally

entitled to other coverage and facilities are reasonably available to you.

4. Health care services during active military duty.

Q. Transplants

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

Transplantation Services in Section 1: Covered Health Care Services.

2. Health care 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 care services for transplants involving animal organs.

R. Travel

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

Services.

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

related to Covered Health Care Services received from a Designated Provider or other Network

provider may be paid back as determined by us. This exclusion does not apply to ambulance

transportation for which Benefits are provided as described under Ambulance Services in Section

1: Covered Health Care Services. This exclusion does not apply to the Travel and Lodging

Program which is described under Section 10: Travel and Lodging Program.

COC23.INS.2018.SG.ME

S. Types of Care

1. Multi-disciplinary pain management programs provided on an inpatient basis for sharp, sudden

pain or for worsened long term 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 for which Benefits are provided as

described under Hospice Care in Section 1: Covered Health Care Services.

6. Rest cures.

7. Services of personal care aides.

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

for specific work).

T. Vision and Hearing

1. Cost and fitting charge for eyeglasses and contact lenses. This exclusion does not apply to

Benefits described under Vision Correction After Surgery or Accident in Section 1: Covered Health

Care Services.

2. Routine vision exams, including refractive exams to determine the need for vision correction.

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

4. Eye exercise or vision therapy.

5. 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.

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

▪ You have craniofacial anomalies whose abnormal or absent ear canals prevent the use of a

wearable hearing aid.

▪ You have hearing loss of sufficient severity that it would not be remedied enough 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 you are enrolled under the Policy.

Repairs and/or replacement for a bone anchored hearing aid when you meet the above coverage

criteria, other than for malfunctions.

U. All Other Exclusions

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

Covered Health Care Services are those health services, including services, supplies, or

Pharmaceutical Products, which we determine to be all of the following:

▪ Provided for the purpose of preventing, evaluating, diagnosing or treating a Sickness, Injury,

Mental Illness, substance-related and addictive disorders, condition, disease or its

symptoms.

▪ Medically Necessary.

▪ Described as a Covered Health Care Service in this Certificate under Section 1: Covered

Health Care Services and in the Schedule of Benefits.

▪ Not otherwise excluded in this Certificate under Section 2: Exclusions and Limitations.

COC23.INS.2018.SG.ME

2. Physical, psychiatric or psychological exams, testing, all forms of vaccinations and immunizations

or treatments that are otherwise covered under the Policy when:

▪ Required only for school, sports or camp, travel, career or employment, insurance, marriage

or adoption.

▪ Related to judicial or administrative proceedings or orders. This exclusion does not apply to

services that are determined to be Medically Necessary.

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

Health Care Services provided during a clinical trial for which Benefits are provided as

described under Clinical Trials in Section 1: Covered Health Care Services.

▪ Required to get or maintain a license of any type.

3. Health care 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 if you

are a civilian injured or otherwise affected by war, any act of war, or terrorism in non-war zones.

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

all health care services, even if the health care service is required to treat a medical condition that

started before the date your coverage under the Policy ended. For more information about

extension of benefits for disabled persons, see Extended Coverage for Total Disability under

Section 4: When Coverage Ends.

5. Health care services when you have no legal responsibility to pay, or when a charge would not

ordinarily be made in the absence of coverage under the Policy.

6. In the event an out-of-Network provider waives, does not pursue, or fails to collect, Co-payments,

Co-insurance and/or any deductible or other amount owed for a particular health care service, no

Benefits are provided for the health care service when the Co-payments, Co-insurance and/or

deductible are waived.

7. Charges in excess of the Allowed Amount, when applicable, or in excess of any specified limitation.

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

blood products. This exclusion does not apply to blood and blood storage related to blood

transfusions.

9. Autopsy.

10. Foreign language and sign language interpretation services offered by or required to be provided

by a Network or out-of-Network provider.

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

Covered Health Care Service, all services related to that non-Covered Health Care Service are

also excluded. This exclusion does not apply to services we would otherwise determine to be

Covered Health Care Services if the service treats complications that arise from the non-Covered

Health Care 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.

12. Health care services from an out-of-Network provider for non-emergent, sub-acute inpatient, or

outpatient services at any of the following non-Hospital facilities: Alternate Facility, Freestanding

Facility, Residential Treatment Facility, Inpatient Rehabilitation Facility, and Skilled Nursing Facility

received outside of the Covered Person's state of residence. For the purpose of this exclusion the

"state of residence" is the state where the Covered Person is a legal resident, plus any

geographically bordering adjacent state or, for a Covered Person who is a student, the state where

they attend school during the school year. This exclusion does not apply in the case of an

Emergency or if authorization has been obtained in advance.

COC23.INS.2018.SG.ME

Section 3: When Coverage Begins

How Do You Enroll?

Eligible Persons must complete an enrollment form given to them by the Group. The Group will submit the

completed forms to us, along with any required Premium. We will not provide Benefits for health care

services that you receive before your effective date of coverage.

What If You Are Hospitalized When Your Coverage Begins?

We will pay Benefits for Covered Health Care Services when all of the following apply:

• You are an inpatient in a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility on the

day your coverage begins.

• You receive Covered Health Care Services on or after your first day of coverage related to that

Inpatient Stay.

• You receive Covered Health Care Services in accordance with the terms of the Policy.

These Benefits are subject to your previous 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 reasonably possible. For plans that have a Network Benefit level, Network Benefits are available only if

you receive Covered Health Care Services from Network providers.

However, if your coverage under this Policy is replacing coverage from another policy between the Group

and a prior carrier, the following conditions may apply. When a health care provider that has been

providing health care services to you is not a Network provider, we will pay Benefits for Covered Health

Care Services in accordance with the following paragraphs in the same manner as if the provider had

been terminated from the Network arranged by us as of the date of policy replacement.

• We will notify you of the termination of the provider's contract at least sixty days in advance of the

termination. When circumstances related to the termination render such notice impossible, we will

provide you as much notice as is reasonably possible. Our notice will include instructions on

obtaining an alternate provider and ensuring that there is no inappropriate disruption in your

ongoing treatment.

• We will permit you to continue to be covered, with respect to the course of treatment with the

provider, for a transitional period of at least sixty days from the date notice to you of the provider's

termination. However, if you are in the second trimester of Pregnancy at the time of the provider's

termination and the provider is treating you during the Pregnancy, the transitional period will extend

through the provision of postpartum care directly related to the Pregnancy.

• We will make coverage of continued treatment by a provider in the previous item conditional upon

the provider's agreeing to the following terms and conditions:

▪ The provider agrees to accept reimbursement from us at rates applicable prior to the start of

the transitional period as payment in full and not to impose cost-sharing with respect to you

in an amount that would exceed the cost-sharing that could have been imposed if the

contract between us and the provider had not terminated.

▪ The provider agrees to adhere to our quality assurance standards and to provide us with the

necessary medical information related to the care provided.

▪ The provider agrees otherwise to adhere to our policies and procedures.

What If You Are Eligible for Medicare?

Your Benefits may be reduced if you are eligible for Medicare but do not enroll in and maintain coverage

under both Medicare Part A and Part B.

COC23.INS.2018.SG.ME

Your Benefits may also be reduced if you are enrolled in a Medicare Advantage (Medicare Part C) plan

but do not follow the rules of that plan. Please see How Are Benefits Paid When You Are Medicare

Eligible? in Section 8: General Legal Provisions for more information about how Medicare may affect your

Benefits.

Who Is Eligible for Coverage?

The Group determines who is eligible to enroll and who qualifies as a Dependent.

Eligible Person

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

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

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

Eligible Persons must live within the United States.

If both spouses are Eligible Persons of the 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 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 Do You Enroll and When Does Coverage Begin?

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

Initial Enrollment Period

When the 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 shown in the Policy. We must receive the completed enrollment form and

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

Open Enrollment Period

The Group sets 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 Group. We must receive the completed enrollment form

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

New Eligible Persons

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

Group. We must 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.

COC23.INS.2018.SG.ME

• Legal adoption.

• Placement for adoption.

• Marriage.

• Legal guardianship.

• Court or administrative order.

• Registering a Domestic Partner.

Coverage for the Dependent begins on the date of the event. We must receive the completed enrollment

form and any required Premium within 31 days of the event.

Coverage exists during the initial 31-day period for a newly born or newly placed or adopted child.

Completed enrollment and payment of any required Premium is required to have such coverage continue

beyond that 31-day period.

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 ended 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:

• Birth.

• Legal adoption.

• Placement for adoption.

• Marriage.

• Registering a Domestic Partner.

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 any of 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. This is true even if the Eligible Person

and/or Dependent continues to receive coverage under the prior plan and to pay the

amounts previously paid by the employer.

▪ In the case of COBRA continuation coverage, the coverage ended.

▪ The Eligible Person and/or Dependent no longer resides, lives or works in an HMO service

area if no other benefit option is available.

COC23.INS.2018.SG.ME

▪ The plan no longer offers benefits to a class of individuals that includes the Eligible Person

and/or Dependent.

▪ 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. We must 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 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.

COC23.INS.2018.SG.ME

Section 4: When Coverage Ends

General Information about When Coverage Ends

As permitted by law, we may end the Policy and/or all similar benefit plans at any time for the reasons

explained in the Policy.

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

are otherwise receiving medical treatment on that date. Please note that this does not affect coverage

that is extended under Extended Coverage for Total Disability below.

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

before the date your coverage ended. However, once your coverage ends, we will not pay claims for any

health care services received after that date (even if the medical condition that is being treated occurred

before the date your coverage ended). Please note that this does not affect coverage that is extended

under Extended Coverage for Total Disability below.

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

ends.

Please note that if you are subject to the Extended Coverage for Total Disability provision later in this

section, entitlement to Benefits ends as described in that section.

What Events End 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 this event, the 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 definitions of the

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

• We Receive Notice to End Coverage

The Group is responsible for providing the required notice to us to end your coverage. Your

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

the Group to end your coverage, or on the date requested in the notice, if later.

• Subscriber Retires or Is Pensioned

The Group is responsible for providing the required notice to us to end your coverage. Your

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

benefits under the Group's pension or retirement plan.

This provision applies unless there is specific coverage classification for retired or pensioned

persons in the Group's Application, and only if the Subscriber continues to meet any applicable

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

is available for retirees.

Fraud or Intentional Misrepresentation of a Material Fact

We will provide at least 30 days advance required notice to the Subscriber that coverage will end on the

date we identify in the notice because you committed an act, practice, or omission that constituted fraud,

or an intentional misrepresentation of a material fact. Examples include knowingly providing incorrect

information relating to another person's eligibility or status as a Dependent. You may appeal this decision

during the notice period. The notice will contain information on how to appeal the decision.

COC23.INS.2018.SG.ME

If we find that you have performed an act, practice, or omission that constitutes fraud, or have made an

intentional misrepresentation of material fact 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.

Third Party Notice of Cancellation

If you suffer from cognitive impairment or functional incapacity, you have the right to designate a third

party to receive prior notice of cancellation for nonpayment of Premium.

You have the right to have your coverage reinstated if the ground for cancellation was for nonpayment of

Premium or other lapse or default on your part. Within 90 days after cancellation, you or your designee

may request reinstatement on the basis that the loss of coverage was a result of cognitive impairment or

functional incapacity. We may require medical proof, at your expense, of one of these conditions.

If your coverage is reinstated, we will request payment for any unpaid Premiums. Within 15 days of the

request, you or your designee must submit payment. If payment is not received, the Policy may not be

reinstated and claims incurred since the date of cancellation will not be eligible for coverage under the

Policy.

If your coverage is not reinstated, we will notify you or your designee of your right to request a hearing

before the Superintendent of the Bureau of Insurance.

Rescission of Coverage

A rescission of coverage is a cancellation or discontinuation of coverage that has a retroactive effect. We

will not rescind coverage under the Policy once it is in effect except in the case of fraud or intentional

misrepresentation of a material fact as outlined in this section.

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 this age if both of the

following are true:

• The Enrolled Dependent child is not able to support him/herself because of mental, developmental,

intellectual, or physical disability.

• The Enrolled Dependent child depends mainly on the Subscriber for support.

Coverage will continue as long as the Enrolled Dependent child is medically certified as disabled and

dependent unless coverage otherwise ends in accordance with the terms of the Policy.

You must furnish us with proof of the medical certification of disability within 31 days of the date coverage

would 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 we choose examine the child. We will pay for that

exam.

We may continue to ask you for proof that the child continues to be disabled and dependent. Such proof

might include medical exams at our expense. We will not ask for this information more than once a year

after the two-year period following the Enrolled Dependent child's attainment of 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 when you are Totally Disabled on the date the entire Policy ends will not end automatically. We

will 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.

COC23.INS.2018.SG.ME

• Six months from the date coverage would have ended when the entire Policy ends.

Continuation of Coverage

If your coverage ends under the Policy, you may have the right 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 Groups that are subject to the terms of COBRA. Contact your plan administrator to find

out if your Group is subject to the provisions of COBRA.

If you chose 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 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 Group or its plan administrator fails to

perform its responsibilities under federal law. Examples of the responsibilities of the 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.

Qualifying Events for Continuation Coverage under State Law

Coverage must have ended due to one of the following qualifying events:

• The Eligible Person was temporarily laid off

• The Eligible Person was permanently laid off and is eligible for premium assistance pursuant to

federal law providing premium assistance for laid-off employees who continue coverage under their

former employer's group health plan as determined by the Superintendent

• The member or Eligible Person lost employment because of an Injury or disease that the Eligible

Person claims to be compensable under former Title 39 or Title 39-A.

Notification Requirements and Election Period for Continuation

Coverage under State Law

You must elect continuation coverage within 31 days of the date your coverage ends. You should get an

election form from the Group or the employer and, once election is made, forward all monthly Premiums

to the 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:

• One year from the date of your last day of work.

• The date coverage ends for failure to make timely payment of the Premium.

• The date coverage ends because you violate a material condition of the Policy.

• The date coverage is or could be obtained under any other group health plan.

• The date the Policy ends.

• When the Workers' Compensation Board determines that the Injury or disease that entitles the

employee to continued coverage under this section is not compensable under Title 39-A.

COC23.INS.2018.SG.ME

Notification of Availability of Individual Coverage

We shall provide forms to the Group and you for the purpose of informing you of your right to purchase

any individual health plan available in the state of Maine, including eligibility for any special enrollment

period to purchase an individual health plan pursuant to the federal Affordable Care Act, and of the

availability of public health coverage options available in the state of Maine, including but not limited to

MaineCare coverage. The form will include the following statements:

• All residents of the state of Maine not eligible for Medicare have a right to purchase any individual

health plan available in the state of Maine.

• In order to avoid a gap in coverage, you should apply for individual coverage prior to termination of

your coverage.

• Information concerning individual coverage is available from the Maine Bureau of Insurance. The

Bureau's toll-free telephone number will be provided.

• Termination of coverage may be a qualifying event for a special enrollment period to purchase an

individual health plan. The length of time for the special enrollment period and the dates for the

next Open Enrollment Period will be provided.

• Financial assistance may be available to you to purchase a qualified health plan through the Maine

Health Insurance Marketplace. The marketplace's publicly accessible website and the toll-free

telephone number will be provided.

• You may qualify for free health coverage through MaineCare. The MaineCare program's publicly

accessible website and toll-free telephone number will be provided.

• You may contact the Health Insurance Consumer Assistance Program for help obtaining health

insurance coverage, including additional information and assistance enrolling in coverage. The

program's publicly accessible website, toll-free telephone number and e-mail address will be

provided.

COC23.INS.2018.SG.ME

Section 5: How to File a Claim

How Are Covered Health Care Services from Network Providers Paid?

We pay Network providers directly for your Covered Health Care Services. You are not responsible for

"balance billing" by Network providers. This means that for Network Benefits you are not responsible for

any difference between the Allowed Amount and the amount the provider bills. If a Network provider bills

you for any Covered Health Care Service, contact us. However, you are required to meet any applicable

deductible and to pay any required Co-payments and Co-insurance to a Network provider.

Claims for office visits that include Preventive Care Services as described under Section 1: Covered

Health Care Services will be paid in accordance with applicable law. You are not responsible for paying

for Preventive Care Services received from a Network provider.

How Are Covered Health Care Services from an Out-of-Network

Provider Paid?

When you receive Covered Health Care Services from an out-of-Network provider, you are responsible

for requesting payment from us although the provider may accept assignment of Benefits. The claim must

be filed. You must file the claim in a format that contains all of the information 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 one year of the date of service, Benefits for that health care service

will be denied or reduced, as determined by us. 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.

Written notice of Sickness or Injury must be provided to us within 30 days after the date when such

Sickness or Injury occurred. Within 15 days of receipt of such notification we will provide forms for filing

proof of loss. Failure to give notice within such time will not invalidate or reduce any claim if it was not

reasonably possible to give such notice and that notice was given as soon as was reasonably possible.

Required Information

We will provide you with forms required to submit proof of loss. If those forms are not provided to you

within 15 days after we receive notice of a claim, you will be deemed to have complied with the

requirements of this section as to proof of loss upon submitting your request for payment within the time

frame reflected in this section.

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.

COC23.INS.2018.SG.ME

• A statement indicating either that you are, or you are not, enrolled for coverage under any other

health 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.

When filing a claim for Outpatient Prescription Drug Benefits, your claims should be submitted to:

Optum Rx

PO Box 650629

Dallas, TX 75265-0629

Payment of Benefits

If you provide written authorization to allow this, all or a portion of any Allowed Amounts due to a provider

may be paid directly to the provider instead of being paid to the Subscriber. We will not reimburse third

parties that have purchased or been assigned benefits by Physicians or other providers.

Benefits will be paid to you unless either of the following is true:

• The provider notifies us that your signature is on file, assigning benefits directly to that provider.

• You make a written request at the time you submit your claim.

Allowed Amounts due to an out-of-Network provider for Covered Health Care Services that are subject to

the No Surprises Act of the Consolidated Appropriations Act (P.L. 116-260) are paid directly to the

provider.

We will either pay or dispute a claim within 30 days after proof of loss is received. A claim that is not paid

or disputed within 30 days is overdue. If during the 30 days we notify you in writing that additional

information is required to review the claim, the claim is not overdue until 30 days after we receive the

additional required information. If payment is not made on an undisputed claim when due, the amount of

the overdue claim or part of the claim will be paid with interest at a rate of 1.5% per month after the due

date.

Payment of Benefits under the Policy shall be in cash or cash equivalents, or in a form of other

consideration that we determine to be adequate. Where Benefits are payable directly to a provider, such

adequate consideration includes the forgiveness in whole or in part of the amount the provider owes us,

or to other plans for which we make payments where we have taken an assignment of the other plans'

recovery rights for value.

COC23.INS.2018.SG.ME

Section 6: Questions, Complaints and Appeals

To resolve a question, complaint, or appeal, just follow these steps:

What if You Have a Question?

Call the telephone number shown on your ID card. Representatives are available to take your call during

regular business hours, Monday through Friday.

What if You Have a Complaint?

Call the telephone number shown on your ID card. 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 representative can provide you with the

address.

If the representative cannot resolve the issue 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 60 days of receiving

it.

Grievance Procedure

A "grievance" is a written complaint submitted by or on behalf of you regarding any of the following:

• Availability, delivery, or quality of health care services, including a complaint regarding an adverse

determination made pursuant to utilization review.

• Claims payment, handling, or reimbursement for health care services.

• Matters pertaining to the contractual relationship between you and us.

If you need assistance in submitting a grievance, you may contact the Superintendent's Office at any

time. The address is:

State of Maine Bureau of Insurance

Superintendent's Office

34 State House Station

Augusta, Maine 04333-0034

Telephone: 1-800-300-5000

Fax: 207-624-8599

First Level Grievance

If you have a grievance concerning any matter, except an adverse utilization review determination, you

(or your representative) may submit it to us. We will issue a written decision to you (or your

representative) within 20 business days after receiving the grievance and all information necessary for

our review of the grievance. Additional time is permitted when we can establish that the 20 day time

frame cannot reasonably be met due to our inability to obtain necessary information from a person or

entity not affiliated with or under contract with us. We will provide written notice of the delay to you (or

your representative). The notice will explain the reasons for the delay. In such instances, decisions must

be issued within 20 days of our receipt of all necessary information.

If we make an adverse determination, our decision will be in writing and will contain the following:

• The names, titles and qualifying credentials of the person or persons participating in the first level

grievance review process (the reviewers).

• A statement of the reviewers' understanding of your grievance and all pertinent facts.

COC23.INS.2018.SG.ME

• The reviewers' decision in clear terms and the basis for the decision.

• A reference to the evidence or documentation used as the basis for the decision.

• Notice of your right to contact the Superintendent's Office including the toll-free telephone number

and address of the Bureau of Insurance.

• A notice describing any external review rights.

• A description of the process to obtain a second level grievance review of a decision, the

procedures and time frames governing a second level grievance review, and the second level

grievance rights.

Utilization Review Procedures

We use the following utilization review procedures described below to review select health care services

against clinical criteria to determine whether the proposed service is a Covered Health Care Service, and

to facilitate clinically appropriate, cost-effective management of your care.

• Pre-service review of selected elective inpatient admissions, surgical day care, and

outpatient/ambulatory procedures to determine whether proposed services meet clinical criteria for

coverage. Prospective utilization review determinations will be made, and you and your providers

will be notified of the determination within two working days of obtaining all necessary information.

• Prior Authorization Requests for Nonemergency Services. Except for a request in exigent

circumstances, a request by a provider for prior authorization of a nonemergency service must be

answered within 72 hours or two business days, whichever is less, in accordance with the

following:

▪ Both the provider and the enrollee on whose behalf the authorization was requested must be

notified of our determination.

▪ If we respond to a request with a request for additional information, we will make a decision

within 72 hours or two business days, whichever is less, after receiving the requested

information.

▪ If we respond that outside consultation is necessary before making a decision, we will make

a decision within 72 hours or two business days, whichever is less, from the time of our initial

response.

▪ The prior authorization standards we use will be clear and readily available.

▪ A provider must make best efforts to provide all information necessary to evaluate a request,

and we will make best efforts to limit requests for additional information.

▪ If we do not grant or deny a request for prior authorization within these timeframes, the

request is granted.

The Policy will not impose a penalty of more than $500 for failure to obtain prior authorization.

• Expedited Review in Exigent Circumstances. When exigent circumstances exist, we must

answer a prior authorization request no more than 24 hours after receiving the request.

▪ Exigent circumstances exist when an enrollee is suffering from a health condition that may

seriously jeopardize the enrollee's life, health or ability to regain maximum function or when

an enrollee is undergoing a current course of treatment using a nonformulary drug.

▪ We must notify the enrollee, the enrollee's designee if applicable, and the provider of its

coverage decision.

• Concurrent utilization review of authorized admissions to hospitals and extended care facilities,

and skilled home health services. Concurrent review decisions will be made within one working day

of obtaining all necessary information, and you and your provider will be notified of the

determination within one working day. In the case of a determination to approve additional

COC23.INS.2018.SG.ME

services, the written notification provided within one working day will include the number of

extended days or next review date, the new total number of days or services approved, and the

date of admission or initiation services. In the case of an adverse determination, we will notify you

and the provider rendering the service within one working day and the service will continue without

liability to your until you have been told of the determination.

• Active case management and discharge planning may also be provided upon the request of the

treating Physician or to assist you in coordinating care.

• Retrospective utilization review may be conducted in situations where services are not subject to

pre-service review against clinical criteria. A determination will be made within 30 working days

from receipt of all necessary information. In the case of a certification, we will notify you and your

provider. In the case of an adverse determination, we will notify you and your provider within five

working days of making the determination.

• Retrospective utilization review for Emergency Health Care Services may be conducted by us

before we deny Benefits or reduce payments for an Emergency Health Care Service based on a

determination of the absence of an Emergency medical condition or a determination that a lower

level of care was needed. A board-certified Emergency Physician who is licensed in Maine shall

conduct such review, including a review of the Covered Person's medical record related to the

Emergency medical condition subject to dispute. If we request records related to a potential denial

of Benefits or payment reduction when Emergency Health Care Services were furnished to a

Covered Person, a provider has an affirmative duty to respond to us in a timely manner. This

paragraph does not apply when we make a reduction in payments for Emergency Health Care

Services based on a contractually agreed upon adjustment.

If you wish to determine the status or outcome of a clinical review decision you may call us at the

telephone number on your ID card.

In the event of an adverse determination involving either a prospective, concurrent or retrospective

clinical review, your treating provider may discuss your case with the Physician reviewer making the

adverse determination or may seek reconsideration from us. The reconsideration will take place within

one working day of the request. The reconsideration will be conducted between the provider rendering

the service and the reviewer who made the adverse determination, or a clinical peer of that provider

designated by the reviewer if the reviewer cannot be available within one working day. If the adverse

determination is not reversed on reconsideration you, or your provider on your behalf, may appeal. Your

appeal rights are described in the following sections. Your right to appeal does not depend on whether or

not your provider sought reconsideration.

Standard Appeals of Adverse Utilization Review Determinations

If you disagree with an adverse utilization review determination or a rescission of coverage determination,

you have the right to appeal that determination. You should follow the procedure contained in the adverse

utilization review determination letter. If any new or additional evidence is relied upon or generated by us

during the determination of the appeal, we will provide it to you free of charge and sufficiently in advance

of the due date of the response to the adverse determination.

We will notify in writing both you and the attending or ordering provider of the decision within 20 working

days following the request for an appeal. Additional time is permitted where we can establish the 20 day

time frame cannot reasonably be met due to our inability to obtain necessary information from a person or

entity not affiliated with or under contract with us. We will provide written notice of the delay to you and

the attending or ordering provider. The notice will explain the reasons for the delay. In such instances,

decisions must be issued within 20 days of our receipt of all necessary information.

Appeals will be conducted by a clinical peer of the treating provider. The clinical peer may not have been

involved in making the initial adverse health care treatment decision unless information not previously

considered during the initial review is provided on appeal. The clinical peer may not be a subordinate of a

clinical peer involved in the prior decision. An adverse health care treatment decision does not include a

rescission determination or initial coverage eligibility determination. A "clinical peer" means a Physician or

other licensed health care practitioner who holds a non-restricted license in a state in the U.S., is board

COC23.INS.2018.SG.ME

certified in the same or similar specialty as typically manages the medical condition, procedure, or

treatment under review, and whose compensation does not depend, directly or indirectly, upon the

quantity, type, or cost of the medical condition, procedure, or treatment that the practitioner approves or

denies on behalf us.

An adverse decision will be in writing and will contain the following:

• The names, titles and qualifying credentials of the person or persons evaluating the appeal.

• A statement of the reviewers' understanding of the reason for your request for an appeal.

• The reviewers' decision in clear terms and the clinical rationale in sufficient detail for you to

respond further to our position.

• A reference to the evidence or documentation used as the basis for the decision, including the

clinical review criteria used to make the determination. The decision will include instructions for

requesting copies of any referenced evidence, documentation or clinical review criteria not

previously provided to you. Where you had previously submitted a written request for the clinical

review criteria relied upon by us in rendering the initial adverse determination, the decision will

include copies of any additional clinical review criteria utilized in arriving at the decision.

• Any appeal rights and the procedure and time limitation for exercising those rights. Notice of

external review rights will be provided as well as a description of the process for submitting a

written request for second level review.

Second Level Review

If you were not satisfied with the written decision concerning your grievance, you may request a second

level review.

For second level grievances involving an adverse utilization review determination, we will appoint a

second level grievance review panel for each grievance. A majority of the panel will be comprised of

health care professionals who are disinterested clinical peers of the treating provider. In cases where

there has been a denial of service, the reviewing health care professionals will not have a financial

interest in the outcome of the review. A majority of the panel will also be comprised of persons who were

not previously involved in the grievance, however a person who was previously involved with the

grievance may be a member of the panel or appear before the panel to present information or answer

questions. The panel must include at least one health care professional who is a clinical peer of the

treating provider and was not previously involved with the grievance.

For second level review of all grievances other than those concerning an adverse utilization review

determination, we will appoint a second level grievance review panel for each grievance. A majority of the

panel will be comprised of our employees or representatives who were not previously involved in the

grievance, however a person who was previously involved with the grievance may be a member of the

panel or appear before the panel to present information or answer questions.

If you request the opportunity to appear in person before our authorized representatives, the procedures

for conducting a second level panel review will be in writing and will contain the following:

• A statement that the review panel will schedule and hold a review meeting within 45 working days

of receiving a request from you for a second level review.

• A statement that the review meeting will be held during regular business hours at a location

reasonably accessible to you. In cases where a face-to-face meeting is not practical for geographic

reasons, we will offer you the opportunity to communicate with the review panel, at our expense, by

conference call, video conferencing, or other appropriate technology.

• A statement that you will be notified in writing at least 15 working days in advance of the review

date. We will not unreasonably deny a request for postponement of the review made by you.

Upon your request, we will provide you with all relevant information that is not confidential or privileged.

You have the right to:

COC23.INS.2018.SG.ME

• Obtain your medical file and information relevant to your appeal free of charge upon request.

• Attend the second level review.

• Present your case to the review panel.

• Submit supporting material both before and at the review meeting.

• Ask questions of any of our representatives.

• Be assisted or represented by a person of your choice.

If we have an attorney present to argue our case against you, we will notify you at least 15 working days

in advance of the review and will advise you of your right to obtain legal representation.

Your right to a fair review will not be made conditional on your appearance at the review.

The review panel will issue a written decision to you within 5 working days of completing the review

meeting.

If you elect not to attend the review committee meeting in person, or participate by telephone, you will be

provided with a written response to your appeal within 30 calendar days of your request for a second level

appeal.

Urgent Appeals that Require Immediate Action

Expedited Review

The following statements apply if you have a dispute about a pending health service, which in the opinion

of your Physician, requires special consideration as an urgent situation.

• The grievance procedures outlined in this section do not apply; and

• Your complaint does not need to be submitted in writing; and

• We will notify you of our decision regarding coverage by the end of the next business day following

the date your complaint is registered, if any decision has been made. If we require additional

information from your Physician in order to make a decision, we will notify you of the decision by

the end of the next business day following receipt of required medical information.

Prescheduled treatments, therapies, surgeries, or other procedures are not considered urgent situations.

If you are in a situation requiring Emergency or urgent care, we will also provide an expedited review. An

Emergency is described in Section 9 - Defined Terms. An urgent care situation is generally considered

one where following the time frame of the standard grievance procedures would seriously jeopardize your

life or health or would jeopardize your ability to regain maximum function. We will provide an expedited

review for all requests concerning an admission, availability of care, continued stay or health care service

for you if you have received Emergency Health Care Services but have not been discharged from a

facility. Adverse determinations made on a retrospective basis may only be appealed through the

standard grievance process. We will provide you, or the provider acting on your behalf, reasonable

access to a clinical peer of the treating provider who can perform an expedited review within one day of

the request. We will then provide you, or the provider acting on your behalf, all necessary information,

including our decision by telephone, fax or the most expeditious method available within 24 hours of

receiving the request. A written confirmation of the decision will follow within two business days of the

decision.

If the expedited review is a concurrent review determination of Emergency Health Care Services as

described in the Emergency Health Care Services - Outpatient section or of an initially noticed admission

or course of treatment, the service shall be continued without liability to you until you have been notified

of the determination.

COC23.INS.2018.SG.ME

If you are dissatisfied with our decision following an expedited review, you, or the provider acting on your

behalf, can then request a second level review. In performing a second level review following an

expedited review, we will adhere to time frames that are reasonable under the circumstances.

Independent External Review Program

You have the right to an independent external review of our adverse health care treatment decision made

by or on behalf of us in accordance with the requirements described in this section. Your failure to obtain

authorization prior to receiving an otherwise Covered Health Care Service may not preclude you from

exercising your rights under this section.

Request for External Review

You or your authorized representative may make a written request for external review of an adverse

health care treatment decision to the Maine Bureau of Insurance. You have the right to waive the Second

Level Review in order to submit an expedited request for external review as described below. A request

for external review must be made within 12 months of the date an enrollee has received a final adverse

health care treatment decision under our internal grievance procedure. You are not required to pay any

filing fee as a condition of processing a request for external review. To initiate an external review call the

Maine Bureau of Insurance at (800) 300-5000 or write to them at 34 State House Station, Augusta, ME

04333.

Expedited Request for External Review

You are not required to exhaust all levels of our internal grievance procedure before filing a request for

external review if any of the following apply:

• We have failed to make a decision on an internal grievance within the time period required or have

otherwise failed to adhere to the requirements applicable to the grievance pursuant to state or

federal law or you have applied for expedited external review at the same time as applying for

expedited internal review.

• We and you mutually agree to bypass the internal grievance process.

• Your life or health is in serious jeopardy.

• You have died.

• The adverse health care treatment decision to be reviewed concerns an admission, availability of

care, a continued stay or health care services when you have received Emergency Health Care

Services but have not been discharged from the facility that provided the Emergency Health Care

Services.

Independent External Review Decision and Timelines

An independent external review decision is binding on us. An external review decision will be made in

accordance with the following requirements:

• In rendering an external review decision, the independent review organization contracted by the

Maine Bureau of Insurance must give consideration to the appropriateness of the requested

Covered Health Care Service based upon the following:

▪ All relevant clinical information relating to your physical and mental condition, including any

competing clinical information.

▪ Any concerns expressed by you concerning your health status.

▪ All relevant clinical standards and guidelines, including, but not limited to, those standards

and guidelines relied upon by us or our utilization review entity.

• An external review decision must be issued in writing and must be based on the evidence

presented by us and you or your authorized representative. You may submit and obtain evidence

COC23.INS.2018.SG.ME

relating to the adverse health care treatment decision under review, attend the external review, ask

questions of any of our representatives present at the external review and use outside assistance

during the review process at your own expense.

• Except as provided in the next paragraph, an external review decision must be rendered by an

independent review organization within 30 days of receipt of a completed request for external

review from the Maine Bureau of Insurance.

• An external review decision must be made as expeditiously as your medical condition requires but

in no event more than 72 hours after receipt of a completed request for external review if the time

frame for review required in the prior paragraph would seriously jeopardize your life or health or

would jeopardize your ability to regain maximum function.

We will provide auxiliary telecommunication devices or qualified interpreter services by a person proficient

in American Sign Language when requested by you if you are deaf or hard-of-hearing or printed materials

in an accessible format, including Braille, large-print materials, computer diskette, audio cassette or a

reader when requested by you when you are visually impaired to allow you to exercise your right to an

external review under this section.

COC23.INS.2018.SG.ME

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 Does Coordination of Benefits Apply?

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.

• Primary Plan. 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.

• Secondary Plan. 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. Allowable Expense is defined below.

Definitions

For purposes of this section, terms are defined as follows:

A. Plan. 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. 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. Order of Benefit Determination Rules. 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

COC23.INS.2018.SG.ME

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. Allowable Expense is a health care expense, including deductibles, Co-

insurance and Co-payments, 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

according to contractual agreement is prohibited from charging a Covered Person is not an

Allowable Expense.

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. 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. 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.

What Are the Rules for Determining the Order of Benefit Payments?

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.

COC23.INS.2018.SG.ME

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 (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 newborn dependent child, the Plan providing maternity coverage for the mother

is the Primary Plan with respect to routine newborn care services provided to the

newborn before the mother's hospital discharge date.

b) For a dependent child (other than a newborn dependent child, as discussed in a)

above) 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.

c) 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.

COC23.INS.2018.SG.ME

(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.

(d) The Plan covering the non-Custodial Parent's spouse.

d) 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.

e) (i) For a dependent child who has coverage under either or both parents' plans and

also has his or her own coverage as a dependent under a spouse's plan, the rule in

paragraph (5) applies.

(ii) In the event the dependent child's coverage under the spouse's plan began on the

same date as the dependent child's coverage under either or both parents' plans, the

order of benefits shall be determined by applying the birthday rule in subparagraph (a)

to the dependent child's parent(s) and the dependent's spouse.

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, 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 the longer period

of time 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.

COC23.INS.2018.SG.ME

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.

C. If a Covered Person is covered under more than one Plan, payments made by the Primary Plan,

payments made by the Covered Person and payments made from a health savings account or

similar fund for benefits covered under the Secondary Plan must be credited toward the Annual

Deductible of the Secondary plan. This does not apply if the Secondary Plan is designed to

supplement the Primary Plan.

D. This Coverage Plan reduces its benefits as described below for Covered Persons who are eligible

for Medicare when Medicare would be the Primary Plan.

Medicare benefits are determined as if the full amount that would have been payable under

Medicare was actually paid under Medicare, even if:

▪ The person is entitled but not enrolled in Medicare. Medicare benefits are determined as if

the person were covered under Medicare Parts A and B.

▪ The person is enrolled in a Medicare Advantage (Medicare Part C) plan and receives non-

covered services because the person did not follow all rules of that plan. Medicare benefits

are determined as if the services were covered under Medicare Parts A and B.

▪ The person receives services from a provider who has elected to opt-out of Medicare.

Medicare benefits are determined as if the services were covered under Medicare Parts A

and B and the provider had agreed to limit charges to the amount of charges allowed under

Medicare rules.

▪ The services are provided in any facility that is not eligible for Medicare reimbursements,

including a Veterans Administration facility, facility of the Uniformed Services, or other facility

of the federal government. Medicare benefits are determined as if the services were

provided by a facility that is eligible for reimbursement under Medicare.

▪ The person is enrolled under a plan with a Medicare Medical Savings Account. Medicare

benefits are determined as if the person were covered under Medicare Parts A and B.

Important: If you are eligible for Medicare on a primary basis (Medicare pays before Benefits

under this Coverage Plan), you should enroll for and maintain coverage under both Medicare Part

A and Part B. If you don't enroll and maintain that coverage, and if we are secondary to Medicare,

we will pay Benefits under this Coverage Plan as if you were covered under both Medicare Part A

and Part B. As a result, your out-of-pocket costs will be higher.

If you have not enrolled in Medicare, Benefits will be determined as if you timely enrolled in

Medicare and obtained services from a Medicare participating provider if either of the following

applies:

▪ You are eligible for, but not enrolled in, Medicare and this Coverage Plan is secondary to

Medicare.

▪ You have enrolled in Medicare but choose to obtain services from a doctor that opts-out of

the Medicare program.

When calculating the Coverage Plan's Benefit in these situations, we use Medicare's approved

amount or Medicare's limiting charge as the Allowable Expense.

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.

COC23.INS.2018.SG.ME

We need to 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.

Does This Plan Have the 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.

How Are Benefits Paid When This Plan is Secondary to Medicare?

If This Plan is secondary to Medicare, then Benefits payable under This Plan will be based on Medicare's

reduced benefits.

COC23.INS.2018.SG.ME

Section 8: General Legal Provisions

What Is Your Relationship with Us?

It is important for you to understand our role with respect to the Group's Policy and how it may affect you.

We help finance or administer the Group's Policy 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 Group's Policy will cover or pay for the health

care that you may receive. The Policy pays for Covered Health Care Services, which are more fully

described in this Certificate.

• The Policy may not pay for all treatments you or your Physician may believe are needed. If the

Policy 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.

What Is Our Relationship with Providers and Groups?

We have agreements in place that govern the relationship between us, our Groups and Network

providers, some of which are affiliated providers. Network providers enter into agreements with us to

provide Covered Health Care Services to Covered Persons.

We do not provide health care services or supplies, or practice medicine. 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. It does not assure the quality of the services provided.

We are not responsible 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 Group's Policy. We are not responsible for fulfilling any duties or obligations of an

employer with respect to the Group's Policy.

The 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 when the Policy ends.

When the 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 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.

What Is Your Relationship with Providers and Groups?

The relationship between you and any provider is that of provider and patient.

You are responsible for all of the following:

• Choosing your own provider.

COC23.INS.2018.SG.ME

• Paying, directly to your provider, any amount identified as a member responsibility, including Co-

payments, Co-insurance, any deductible and any amount that exceeds the Allowed Amount, when

applicable.

• Paying, directly to your provider, the cost of any non-Covered Health Care Service.

• Deciding if any provider treating you is right for you. This includes Network providers you choose

and providers that they refer.

• Deciding 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 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 Group, that notice is deemed notice to all affected Subscribers and their Enrolled Dependents. The

Group is responsible for giving notice to you.

If the Premium rate in our agreement with the Group changes, we will provide written notice to the

Subscriber at least 60 days in advance of the effective date of the change.

Statements by Group or Subscriber

All statements in any application for insurance made by the Group or by a Subscriber shall, in the

absence of fraud, be deemed representations and not warranties. We will not use any statement made by

the Group to void the Policy after it has been in force for two years unless it is a fraudulent statement.

No action at law or in equity shall be brought to recover on the Policy prior to the expiration of 60 days

after proof of loss has been filed in accordance with the requirements of the Policy and that no such

action shall be brought at all, unless brought within 2 years from the expiration of the time within which

proof of loss is required by the policy.

Do We Pay Incentives to Providers?

We pay Network providers through various types of contractual arrangements. Some of these

arrangements 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

care 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.

• Bundled payments - certain Network providers receive a bundled payment for a group of Covered

Health Care Services for a particular procedure or medical condition. The applicable Co-payment

and/or Co-insurance will be calculated based on the provider type that received the bundled

payment. The Network providers receive these bundled payments 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. If you receive follow-up services related to a procedure where a bundled payment is

made, an additional Co-payment and/or Co-insurance may not be required if such follow-up

services are included in the bundled payment. You may receive some Covered Health Care

Services that are not considered part of the inclusive bundled payment and those Covered Health

COC23.INS.2018.SG.ME

Care Services would be subject to the applicable Co-payment and/or Co-insurance as described in

the Schedule of Benefits.

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 call 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.

Are Incentives Available to You?

Sometimes we may offer coupons, enhanced Benefits, or other incentives to encourage you to take part

in various programs, including wellness programs, certain disease management programs, surveys,

discount programs and/or programs to seek care in a more cost effective setting and/or from Designated

Providers. In some instances, these programs may be offered in combination with a non-

UnitedHealthcare entity. The decision about whether or not to take part in a program is yours alone.

However, we recommend that you discuss taking part in such programs with your Physician. Contact us

at www.myuhc.com or the telephone number on your ID card if you have any questions.

Do We Receive 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. As determined by us, we may pass a portion of these

rebates on to you. When rebates are passed onto you, they may be taken into account in determining

your Co-payment and/or Co-insurance.

Who Interprets Benefits and Other Provisions under the Policy?

We have the authority 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 assign this 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 offer Benefits for

services that would otherwise not be Covered Health Care 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.

Who Provides Administrative Services?

We provide administrative services or, as we determine, we may arrange for various persons or entities to

provide administrative services, 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 as we determine. 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 have the right, as we determine and without your approval, to change,

interpret, withdraw or add Benefits or end 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 amended to conform

to the minimum requirements of such statutes and regulations.

COC23.INS.2018.SG.ME

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 and consistent with applicable notice requirements. All of the following

conditions apply:

• Amendments and Riders to the Policy are effective upon the Group's next anniversary date, except

as otherwise permitted by law.

• 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.

• Amendment and Rider language must have been filed with and approved by the Maine Bureau of

Insurance prior to issuance.

However, when renewing the Policy in accordance with this section, we may modify the coverage, terms

and conditions of the Policy consistent with other applicable provisions of state and federal laws as long

as the modifications are applied uniformly to all policyholders of the same product.

We will provide written notice to the Subscriber at least 60 days in advance of any material modification,

including changes in Preventive Care Services.

How Do We Use Information and Records?

We may use your individually identifiable health information as follows:

• To administer the Policy and pay claims.

• To identify procedures, products, or services that you may find valuable.

• 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 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 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 records concerning health care services when any of the following apply:

• Needed to put in place and administer the terms of the Policy.

• Needed for medical review or quality assessment.

• Required 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 you may 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 needed. Our designees have the

same rights to this information as we have.

COC23.INS.2018.SG.ME

Do We Require 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. We also have the right to make an autopsy in case

of death where it is not prohibited by law.

Is Workers' Compensation Affected?

Benefits provided under the Policy do not substitute for and do not affect any requirements for coverage

by workers' compensation insurance.

How Are Benefits Paid When You Are Medicare Eligible?

Benefits under the Policy are not intended to supplement any coverage provided by Medicare.

Nevertheless, in some circumstances Covered Persons who are eligible for or enrolled in Medicare may

also be enrolled under the Policy.

If you are eligible for or enrolled in Medicare, please read the following information carefully.

If you are eligible for Medicare on a primary basis (Medicare pays before Benefits under the Policy), you

should enroll in and maintain coverage under both Medicare Part A and Part B. If you don't enroll and

maintain that coverage, and if we are the secondary payer as described in Section 7: Coordination of

Benefits, we will pay Benefits under the Policy as if you were covered under both Medicare Part A and

Part B. As a result, you will be responsible for the costs that Medicare would have paid and you will incur

a larger out-of-pocket cost.

If you are enrolled in a Medicare Advantage (Medicare Part C) plan on a primary basis (Medicare pays

before Benefits under the Policy), you should follow all rules of that plan that require you to seek services

from that plan's participating providers. When we are the secondary payer, we will pay any Benefits

available to you under the Policy as if you had followed all rules of the Medicare Advantage plan. You will

be responsible for any additional costs or reduced Benefits that result from your failure to follow these

rules, and you will incur a larger out-of-pocket cost.

Subrogation and Reimbursement

We have the right to subrogation and reimbursement. References to "you" or "your" in this Subrogation

and Reimbursement section shall include you, your Estate and your heirs and beneficiaries unless

otherwise stated.

Subrogation applies when we have paid Benefits on your behalf for a Sickness or Injury for which any

third party is allegedly responsible. The right to subrogation means that we are substituted to and shall

succeed to any and all legal claims that you may be entitled to pursue against any third party for the

Benefits that we have paid that are related to the Sickness or Injury for which any third party is considered

responsible.

Subrogation Example:

Suppose you are injured in a car Accident that is not your fault, and you receive Benefits under the Policy

to treat your injuries. Under subrogation, the Policy has the right to take legal action in your name against

the driver who caused the Accident and that driver's insurance carrier to recover the cost of those

Benefits.

The right to reimbursement means that if it is alleged that any third party caused or is responsible for a

Sickness or Injury for which you receive a settlement, judgment, or other recovery from any third party,

you must use those proceeds to fully return to us 100% of any Benefits you receive for that Sickness or

Injury. The right of reimbursement shall apply to any benefits received at any time until the rights are

extinguished, resolved or waived in writing.

Reimbursement Example:

COC23.INS.2018.SG.ME

Suppose you are injured in a boating Accident that is not your fault, and you receive Benefits under the

Policy as a result of your injuries. In addition, you receive a settlement in a court proceeding from the

individual who caused the Accident. You must use the settlement funds to return to the Policy 100% of

any Benefits you received to treat your injuries.

The following persons and entities are considered third parties:

• A person or entity alleged to have caused you to suffer a Sickness, Injury or damages, or who is

legally responsible for the Sickness, Injury or damages.

• Any insurer or other indemnifier of any person or entity alleged to have caused or who caused the

Sickness, Injury or damages.

• Your employer in a workers' compensation case or other matter alleging liability.

• 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 resulting from injuries or damages

for which Benefits were provided.

• Any person or entity against whom you may have any claim for professional and/or legal

malpractice arising out of or connected to a Sickness or Injury you allege or could have alleged

were the responsibility of any third party.

• Any person or entity that is liable for payment to you on any equitable or legal liability theory for

injuries or damages for which Benefits were provided.

You agree as follows:

• You will cooperate with us in protecting our legal and equitable rights to subrogation and

reimbursement in a timely manner, including, but not limited to:

▪ Notifying us, in writing, of any potential legal claim(s) you may have against any third party

for acts which caused Benefits to be paid or become payable.

▪ 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.

▪ Obtaining our consent or our agents' consent before releasing any party from liability or

payment of medical expenses.

▪ Complying with the terms of this section.

Your failure to cooperate with us is considered a breach of contract. As such, we have the right to

terminate or deny future Benefits, take legal action against you, and/or set off from any future

Benefits the value of Benefits we have paid relating to any Sickness or Injury alleged to have been

caused or caused by any third party to the extent not recovered by us due to you or your

representative not cooperating with us. If we incur attorneys' fees and costs in order to collect third

party settlement funds held by you or your representative, we have the right to recover those fees

and costs from you. You will also be required to pay interest on any amounts you hold which

should have been returned to us.

• We have a first priority right to receive payment on any claim against any third party before you

receive payment from that third party. Further, our first priority right to payment is superior to any

and all claims, debts or liens asserted by any medical providers, including but not limited to

hospitals or emergency treatment facilities, that assert a right to payment from funds payable from

or recovered from an allegedly responsible third party and/or insurance carrier.

COC23.INS.2018.SG.ME

• Our subrogation and reimbursement rights apply to full and partial settlements, judgments, or other

recoveries paid or payable to you or your representative, your Estate, your heirs and beneficiaries,

no matter how those proceeds are captioned or characterized. Payments include, but are not

limited to, economic, non-economic, pecuniary, consortium and punitive damages. We are not

required to help you to pursue your claim for damages or personal injuries and no amount of

associated costs, including attorneys' fees, shall be deducted from our recovery without our

express written consent. No so-called "Fund Doctrine" or "Common Fund Doctrine" or "Attorney's

Fund Doctrine" shall defeat this right.

• Regardless of whether 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, no matter

how those proceeds are captioned or characterized. Proceeds from which we may collect include,

but are not limited to, economic, non-economic, and punitive damages. No "collateral source" rule,

any "Made-Whole Doctrine" or "Make-Whole Doctrine," claim of unjust enrichment, nor any other

equitable limitation shall limit our subrogation and reimbursement rights.

• Benefits paid by us may also be considered to be Benefits advanced.

• If you receive any payment from any party as a result of Sickness or Injury, and we allege some or

all of those funds are due and owed to us, you and/or your representative shall hold those funds in

trust, either in a separate bank account in your name or in your representative's trust account.

• By participating in and accepting Benefits under the Policy, you agree that (i) any amounts

recovered by you from any third party shall constitute Policy assets (to the extent of the amount of

Benefits provided on behalf of the Covered Person), (ii) you and your representative shall be

fiduciaries of the Policy (within the meaning of ERISA) with respect to such amounts, and (iii) you

shall be liable for and agree to pay any costs and fees (including reasonable attorney fees)

incurred by us to enforce its reimbursement rights.

• Our right to recovery will not be reduced due to your own negligence.

• By participating in and accepting Benefits from us, you agree to assign to us any benefits, claims or

rights of recovery you have under any automobile policy - including no-fault benefits, PIP benefits

and/or medical payment benefits - other coverage or against any third party, to the full extent of the

Benefits we have paid for the Sickness or Injury. By agreeing to provide this assignment in

exchange for participating in and accepting benefits, you acknowledge and recognize our right to

assert, pursue and recover on any such claim, whether or not you choose to pursue the claim, and

you agree to this assignment voluntarily.

• We may, at our option, take necessary and appropriate action to preserve our rights under these

provisions, including but not limited to, providing or exchanging medical payment information with

an insurer, the insurer's legal representative or other third party; filing an ERISA reimbursement

lawsuit to recover the full amount of medical benefits you receive for the Sickness or Injury out of

any settlement, judgment or other recovery from any third party considered responsible; and filing

suit in your name or your Estate's name, which does not obligate us in any way to pay you part of

any recovery we might obtain. Any ERISA reimbursement lawsuit stemming from a refusal to

refund Benefits as required under the terms of the Policy is governed by a six-year statute of

limitations.

• You may not accept any settlement that does not fully reimburse us, without our written approval.

• We have the authority to resolve all disputes regarding the interpretation of the language stated

herein.

• In the case of your death, giving rise to any wrongful death or survival claim, the provisions of this

section apply to your estate, the personal representative of your estate, and your heirs or

beneficiaries. In the case of your death our right of reimbursement and right of subrogation shall

apply if a claim can be brought on behalf of you or your estate that can include a claim for past

COC23.INS.2018.SG.ME

medical expenses or damages. The obligation to reimburse us is not extinguished by a release of

claims or settlement agreement of any kind.

• No allocation of damages, settlement funds or any other recovery, by you, your estate, the

personal representative of your estate, your heirs, your beneficiaries or any other person or party,

shall be valid if it does not reimburse us for 100% of our interest unless we provide written consent

to the allocation.

• The provisions of this section apply to the parents, guardian, or other representative of a

Dependent child who incurs a Sickness or Injury caused by any third party. If a parent or guardian

may bring a claim for damages arising out of a minor's Sickness or Injury, the terms of this

subrogation and reimbursement clause shall apply to that claim.

• If any third party causes or is alleged to have caused you to suffer a Sickness or Injury while you

are covered under the Policy, the provisions of this section continue to apply, even after you are no

longer covered.

• In the event that you do not abide by the terms of the Policy pertaining to reimbursement, we may

terminate Benefits to you, your dependents or the subscriber, deny future Benefits, take legal

action against you, and/or set off from any future Benefits the value of Benefits we have paid

relating to any Sickness or Injury alleged to have been caused or caused by any third party to the

extent not recovered by us due to your failure to abide by the terms of the Policy. If we incur

attorneys' fees and costs in order to collect third party settlement funds held by you or your

representative, we have the right to recover those fees and costs from you. You will also be

required to pay interest on any amounts you hold which should have been returned to us.

• We and all Administrators administering the terms and conditions of the Policy's subrogation and

reimbursement rights have such powers and duties as are necessary to discharge its duties and

functions, including the exercise of our authority to (1) construe and enforce the terms of the

Policy's subrogation and reimbursement rights and (2) make determinations with respect to the

subrogation amounts and reimbursements owed to us.

In applying the provisions of this section, the following applies:

• Your prior written approval is required.

• Payments are made only on a just and equitable basis and not on the basis of a priority lien. "A just

and equitable basis" means that any factors that diminish the potential value of the claim will

likewise reduce the share in the claim for those claiming payment for services or reimbursement.

Such factors include, but are not limited to:

▪ Legal defenses. Questions of liability and comparative negligence or other legal defenses.

▪ Exigencies of trial. Exigencies of trial that reduce a settlement award in order to resolve the

claim.

▪ Limits of coverage. Limits on the amount of applicable insurance coverage that reduce the

claim to an amount recoverable by you.

When Do We Receive Refunds of Overpayments?

If we pay Benefits for expenses incurred on your account, you, 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 or did not legally have to be paid by you.

• 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, you agree to help us get the refund when

requested.

COC23.INS.2018.SG.ME

If the refund is due from you and you do not promptly refund the full amount, we may recover the

overpayment by reallocating the overpaid amount to pay, in whole or in part, your future Benefits that are

payable under the Policy. If the refund is due from a person or organization other than you, we may

recover the overpayment by reallocating the overpaid amount to pay, in whole or in part; (i) future

Benefits that are payable in connection with services provided to other Covered Persons under the Policy;

or (ii) future Benefits that are payable in connection with services provided to persons under other plans

for which we make payments, pursuant to a transaction in which our overpayment recovery rights are

assigned to such other plans in exchange for such plans' remittance of the amount of the reallocated

payment.

The reductions will equal the amount of the required refund. We may have other rights in addition to the

right to reduce future benefits.

Is There a 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.

When is Continuity of Coverage Under Maine Law Provided?

Continuity of coverage is provided under Maine law within 90 days before the date you were either:

• Enrolled under this Policy; or

• Would have been eligible to enroll except for a waiting period for coverage established by the

Group, provided you enrolled when initially eligible to do so.

Continuity of coverage is provided under Maine law within 180 days before the date you enrolled under

the Policy (or would have been eligible except for a waiting period for coverage established by the Group

and you did enroll when initially eligible), if all of the following conditions are met:

• Prior coverage was terminated due to unemployment.

• You received unemployment compensation for the period of unemployment.

• You were employed when coverage commenced under this Policy.

What Is the Entire Policy?

The Policy, this Certificate, the Schedule of Benefits, the Group's Application and any Riders and/or

Amendments, make up the entire Policy that is issued to the Group.

COC23.INS.2018.SG.ME

Section 9: Defined Terms

Accident/Accidental - accidental bodily Injury sustained by you while this Policy is in force and that is the

direct cause of the condition for which Benefits are provided.

Air Ambulance - medical transport by rotary wing Air Ambulance or fixed wing Air Ambulance as defined

in 42 CFR 414.605.

Allowed Amounts - for Covered Health Care Services, incurred while the Policy is in effect, Allowed

Amounts are determined by us or determined as required by law as shown in the Schedule of Benefits.

Allowed Amounts are determined in accordance with our reimbursement policy guidelines or as required

by law. We develop these guidelines, as we determine, after review of all provider billings in accordance

with one or more of the following methodologies:

• As shown 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.

Alternate Facility - a health care facility that is not a Hospital. It provides one or more of the following

services on an outpatient basis, as permitted by law:

• Surgical services.

• Emergency Health Care Services.

• Rehabilitative, laboratory, diagnostic or therapeutic services.

It may also provide Mental Health Care Services or Substance-Related and Addictive Disorders Services

on an outpatient or inpatient basis.

Amendment - any attached written description of added or changed provisions to the Policy. It is

effective only when signed by us. It is subject to all conditions, limitations and exclusions of the Policy,

except for those that are specifically amended.

Ancillary Services - items and services provided by out-of-Network Physicians at a Network facility that

are any of the following:

• Related to emergency medicine, anesthesiology, pathology, radiology, and neonatology;

• Provided by assistant surgeons, hospitalists, and intensivists;

• Diagnostic services, including radiology and laboratory services, unless such items and services

are excluded from the definition of Ancillary Services as determined by the Secretary;

• Provided by such other specialty practitioners as determined by the Secretary; and

• Provided by an out-of-Network Physician when no other Network Physician is available.

Annual Deductible - the total of the Allowed Amount or the Recognized Amount when applicable, you

must pay for Covered Health Care Services per year before we will begin paying for Benefits. It does not

include any amount that exceeds Allowed Amounts or Recognized Amounts when applicable. The

Schedule of Benefits will tell you if your plan is subject to payment of an Annual Deductible and how it

applies.

Autism Spectrum Disorder - any of the pervasive developmental disorders as defined by the current

edition of the Diagnostic and Statistical Manual of the American Psychiatric Association including autistic

disorder, Asperger's disorder and pervasive developmental disorder not otherwise specified.

Benefits - your right to payment for Covered Health Care Services that are available under the Policy.

COC23.INS.2018.SG.ME

Biologically-based Mental Illness - any of the following biologically-based Mental Illness as defined in

the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association as a

biologically-based mental illness (except for those that are designated as "V" codes):

• Psychotic disorders, including schizophrenia.

• Dissociative disorders.

• Mood disorders.

• Anxiety disorders.

• Personality disorders.

• Paraphilias.

• Attention deficit and disruptive behavior disorders.

• Pervasive developmental disorders.

• Tic disorders.

• Eating disorders including bulimia and anorexia.

• Substance use disorders.

Cellular Therapy - administration of living whole cells into a patient for the treatment of disease.

Co-insurance - the charge, stated as a percentage of the Allowed Amount or the Recognized Amount

when applicable, that you are required to pay for certain Covered Health Care 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.

Co-payment - the charge, stated as a set dollar amount, that you are required to pay for certain Covered

Health Care Services.

Please note that for Covered Health Care Services, you are responsible for paying the lesser of the

following:

• The Co-payment.

• The Allowed Amount or the Recognized Amount when applicable.

Cosmetic Procedures - procedures or services that change or improve appearance without significantly

improving physiological function.

Covered Health Care Service(s) - health care services, including supplies or Pharmaceutical Products,

which we determine to be all of the following:

• Provided for the purpose of preventing, evaluating, diagnosing or treating a Sickness, Injury,

Mental Illness, substance-related and addictive disorders, condition, disease or its symptoms.

• Medically Necessary.

• Described as a Covered Health Care Service in this Certificate under Section 1: Covered Health

Care Services and in the Schedule of Benefits.

• Not excluded in this Certificate under Section 2: Exclusions and Limitations.

Covered Person - the Subscriber or a Dependent, but this term applies only while the person is enrolled

under the Policy. We use "you" and "your" in this Certificate to refer to a Covered Person.

Custodial Care - services that are any of the following non-Skilled Care services:

• Non health-related services such as help with daily living activities. Examples include eating,

dressing, bathing, transferring and ambulating.

COC23.INS.2018.SG.ME

• Health-related services that can safely and effectively be performed by trained non-medical

personnel and are provided for the primary purpose of meeting the personal needs of the patient or

maintaining a level of function, as opposed to improving that function to an extent that might allow

for a more independent existence.

Definitive Drug Test - test to identify specific medications, illicit substances and metabolites and is

qualitative or quantitative to identify possible use or non-use of a drug.

Dependent - the Subscriber's legal spouse or a child of the Subscriber or the Subscriber's spouse. All

references to the spouse of a Subscriber shall include a Domestic Partner, except for the purpose of

coordinating Benefits with Medicare. As described in Section 3: When Coverage Begins, the Group

determines who is eligible to enroll and who qualifies as a Dependent. The term "child" includes:

• 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 for whom health care coverage is required through a Qualified Medical Child Support Order

or other court or administrative order. The Group is responsible for determining if an order meets

the criteria of a Qualified Medical Child Support Order.

The following conditions apply:

• A Dependent includes a child listed above under age 26.

• A child is no longer eligible as a Dependent on the last day of the month following the date the child

reaches age 26 except as provided in Section 4: When Coverage Ends under Coverage for a

Disabled Dependent Child.

A child who meets the requirements set forth above ceases to be eligible as a Dependent on the last day

of the month following the date the child reaches age 26.

The Subscriber must reimburse us for any Benefits paid during a time a child did not satisfy these

conditions.

A Dependent does not include anyone who is also enrolled as a Subscriber. No one can be a Dependent

of more than one Subscriber.

Designated Dispensing Entity - a pharmacy, provider, or facility that has entered into an agreement with

us, or with an organization contracting on our behalf, to provide Pharmaceutical Products for the

treatment of specified diseases or conditions. Not all Network pharmacies, providers, or facilities are

Designated Dispensing Entities.

Designated Network Benefits - the description of how Benefits are paid for certain Covered Health Care

Services provided by a provider or facility that has been identified as a Designated Provider. The

Schedule of Benefits will tell you if your plan offers Designated Network Benefits and how they apply.

Designated Provider - a provider and/or facility that:

• Has entered into an agreement with us, or with an organization contracting on our behalf, to

provide Covered Health Care Service for the treatment of specific diseases or conditions; or

• We have identified through our designation programs as a Designated Provider. Such designation

may apply to specific treatments, conditions and/or procedures.

A Designated Provider may or may not be located within your geographic area. Not all Network Hospitals

or Network Physicians are Designated Providers.

COC23.INS.2018.SG.ME

You can find out if your provider is a Designated Provider by contacting us at www.myuhc.com or the

telephone number on your ID card.

Designated Virtual Network Provider - a provider or facility that has entered into an agreement with us,

or with an organization contracting on our behalf, to deliver Covered Health Care Services through live

audio with video technology or audio only.

Domestic Partner - One of 2 unmarried adults who are domiciled together under long-term

arrangements that evidence a commitment to remain responsible indefinitely for each other's welfare.

Domestic Partnership - a relationship between a Subscriber and one other person of the opposite or

same sex. All of the following requirements apply to both persons. They must:

• Not be currently married to, or a Domestic Partner of, another person under either statutory or

common law.

• Share the same permanent residence and the common necessities of life.

• Be at least 18 years of age.

• Be mentally able to consent to contract.

• They must be financially interdependent and they have furnished documents to support at least two

of the following conditions of such financial interdependence:

▪ They have a single dedicated relationship of at least 6 - 12 months.

▪ They have joint ownership of a residence.

▪ They have at least two of the following:

♦ A joint ownership of an automobile.

♦ A joint checking, bank or investment account.

♦ A joint credit account.

♦ A lease for a residence identifying both partners as tenants.

♦ A will and/or life insurance policies which designates the other as primary beneficiary.

The Subscriber and Domestic Partner must jointly sign the required affidavit of Domestic Partnership.

Durable Medical Equipment (DME) - medical equipment that is all of the following:

• 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 DME.

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

• Serves a medical purpose for the treatment of a Sickness or Injury.

• Primarily used within the home.

Eligible Person - an employee of the Group or other person connected to the Group who meets the

eligibility requirements shown in both the Group's Application and the Policy. An Eligible Person must live

within the United States.

Emergency - the sudden and, at the time, unexpected onset of a physical or mental health condition,

including severe pain, manifesting itself by symptoms of sufficient severity, regardless of the final

diagnosis that is given, that would lead a prudent layperson, possessing an average knowledge of

medicine and health, to believe:

• That the absence of immediate medical attention for an individual could reasonably be expected to

result in:

COC23.INS.2018.SG.ME

▪ Placing the physical or mental health of the individual or, with respect to a pregnant woman,

the health of the pregnant woman or her unborn child in serious jeopardy;

▪ Serious impairment of a bodily function; or

▪ Serious dysfunction of any organ or body part; or

• With respect to a pregnant woman who is having contractions, that there is:

▪ Inadequate time to effect a safe transfer of the woman to another hospital before delivery; or

▪ A threat to the health or safety of the woman or unborn child if the woman were to be

transferred to another hospital.

Emergency Health Care Services - health care item or service furnished or required to evaluate and

treat an Emergency medical condition that is provided in an Emergency facility or setting as follows:

• An appropriate medical screening exam (as required under section 1867 of the Social Security Act

or as would be required under such section if such section applied to an Independent Freestanding

Emergency Department) that is within the capability of the emergency department of a Hospital, or

an Independent Freestanding Emergency Department, as applicable, including ancillary services

routinely available to the emergency department to evaluate such Emergency, and

• Such further medical exam and treatment, to the extent they are within the capabilities of the staff

and facilities available at the Hospital or an Independent Freestanding Emergency Department, as

applicable, as are required under section 1867 of the Social Security Act, or as would be required

under such section if such section applied to an Independent Freestanding Emergency

Department, to stabilize the patient (regardless of the department of the Hospital in which such

further exam or treatment is provided). For the purpose of this definition, "to stabilize" has the

meaning as given such term in section 1867(e)(3) of the Social Security Act (42 U.S.C.

1395dd(e)(3)).

• Emergency Health Care Services include items and services otherwise covered under the Policy

when provided by an out-of-Network provider or facility (regardless of the department of the

Hospital in which the items and services are provided) after the patient is stabilized and as part of

outpatient observation, or an Inpatient Stay or outpatient stay that is connected to the original

Emergency, unless each of the following conditions are met:

a) The attending Emergency Physician or treating provider determines the patient is able to

travel using nonmedical transportation or non-Emergency medical transportation to an

available Network provider or facility located within a reasonable distance taking into

consideration the patient's medical condition.

b) The provider furnishing the additional items and services satisfies notice and consent

criteria in accordance with applicable law.

c) The patient is in such a condition to receive information as stated in b) above and to

provide informed consent in accordance with applicable law.

d) The provider or facility satisfies any additional requirements or prohibitions as may be

imposed by state law.

e) Any other conditions as specified by the Secretary.

The above conditions do not apply to unforeseen or urgent medical needs that arise at the time the

service is provided regardless of whether notice and consent criteria has been satisfied.

Enrolled Dependent - a Dependent who is properly enrolled under the Policy.

Experimental or Investigational Service(s) - medical, surgical, diagnostic, psychiatric, mental health,

substance-related and addictive 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:

COC23.INS.2018.SG.ME

1. Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the

proposed use and not identified as appropriate for proposed use in any of the following standard

reference compendia:

▪ AHFS Drug Information (AHFS DI) under therapeutic uses section;

▪ Elsevier Gold Standard's Clinical Pharmacology under the indications section;

▪ DRUGDEX System by Micromedex under the therapeutic uses section and has a strength

recommendation rating of class I, class IIa, or class IIb; or

▪ National Comprehensive Cancer Network (NCCN) drugs and biologics compendium

category of evidence 1, 2A, or 2B.

2. 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 Experimental or

Investigational.)

3. 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.

4. Only obtainable, with regard to outcomes for the given indication, within research settings.

Exceptions:

• Clinical trials for which Benefits are available as described under Clinical Trials in Section 1:

Covered Health Care Services.

• We may, as we determine, consider an otherwise Experimental or Investigational Service to be a

Covered Health Care Service for that Sickness or condition if:

▪ You are not a participant in a qualifying clinical trial, as described under Clinical Trials in

Section 1: Covered Health Care Services; and

▪ You have a Sickness or condition that is likely to cause death within one year of the request

for treatment.

Prior to such a consideration, we must first establish that there is sufficient evidence to conclude

that, even though unproven, the service has significant potential as an effective treatment for that

Sickness or condition.

Freestanding Facility - an outpatient, diagnostic or ambulatory center or independent laboratory which

performs services and submits claims separately from a Hospital.

Gene Therapy - therapeutic delivery of nucleic acid (DNA or RNA) into a patient's cells as a drug to treat

a disease.

Genetic Counseling - counseling by a qualified clinician that includes:

• Identifying your potential risks for suspected genetic disorders;

• An individualized discussion about the benefits, risks and limitations of Genetic Testing to help you

make informed decisions about Genetic Testing; and

• Interpretation of the Genetic Testing results in order to guide health decisions.

Certified genetic counselors, medical geneticists and Physicians with a professional society's certification

that they have completed advanced training in genetics are considered qualified clinicians when Covered

Health Care Services for Genetic Testing require Genetic Counseling.

Genetic Testing - exam of blood or other tissue for changes in genes (DNA or RNA) that may indicate an

increased risk for developing a specific disease or disorder, or provide information to guide the selection

of treatment of certain diseases, including cancer.

COC23.INS.2018.SG.ME

Gestational Carrier - a female who becomes pregnant by having a fertilized egg (embryo) implanted in

her uterus for the purpose of carrying the fetus to term for another person. The Gestational Carrier does

not provide the egg and is therefore not biologically related to the child.

Group - the employer, or other defined or otherwise legally established group, to whom the Policy is

issued.

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 mainly engaged in providing inpatient health care services, for the short term care and

treatment of injured or sick persons. 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 mainly a place for rest, Custodial Care or care of the aged. It is not a nursing home,

convalescent home or similar institution.

Hospital-based Facility - an outpatient facility that performs services and submits claims as part of a

Hospital.

Iatrogenic Infertility - an impairment of fertility by surgery, radiation, chemotherapy, or other medical

treatment affecting reproductive organs or processes.

Independent Freestanding Emergency Department - a health care facility that:

• Is geographically separate and distinct and licensed separately from a Hospital under applicable

state law; and

• Provides Emergency Health Care Services.

Initial Enrollment Period - the first period of time when Eligible Persons may enroll themselves and their

Dependents under the Policy.

Injury - damage to the body, including all related conditions and symptoms.

Inpatient Rehabilitation Facility - any of the following that provides inpatient rehabilitation health care

services (including physical therapy, occupational therapy and/or speech therapy), as authorized by law:

• A long term acute rehabilitation center,

• A Hospital, or

• A special unit of a Hospital designated as an Inpatient Rehabilitation Facility.

Inpatient Stay - a continuous stay that follows formal admission to a Hospital, Skilled Nursing Facility or

Inpatient Rehabilitation Facility.

Intensive Behavioral Therapy (IBT) - outpatient Mental Health Care Services that aim to reinforce

adaptive behaviors, reduce maladaptive behaviors and improve the mastery of functional age appropriate

skills in people with Autism Spectrum Disorders. The most common IBT is Applied Behavior Analysis

(ABA).

Intensive Outpatient Treatment - a structured outpatient treatment program.

• For Mental Health Care Services, the program may be freestanding or Hospital-based and provides

services for at least three hours per day, two or more days per week.

• For Substance-Related and Addictive Disorders Services, the program provides nine to nineteen

hours per week of structured programming for adults and six to nineteen hours for adolescents,

consisting primarily of counseling and education about addiction related and mental health

problems.

COC23.INS.2018.SG.ME

Intermittent Care - skilled nursing care that is provided 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 certain circumstances when the need for more care is finite and predictable.

Medically Necessary - Medically Necessary health care means health care services or products

provided to an enrollee for the purpose of preventing, diagnosing or treating and illness, Injury or disease

or the symptoms of an illness, Injury or disease in a manner that is:

• Consistent with Generally Accepted Standards of Medical Practice.

• Clinically appropriate, in terms of type, frequency, extent, service site and duration.

• Demonstrated through scientific evidence to be effective in improving health outcomes.

• Representative of "best practices" in the medical profession.

• Not primarily for the convenience of the enrollee or Physician or other health care practitioner.

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 have 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 determined by us.

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

determinations regarding specific services. These clinical policies (as developed by us and revised from

time to time), are available to Covered Persons through www.myuhc.com or the telephone number on

your ID card. They are also available to Physicians and other health care professionals on

UHCprovider.com.

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 Care Services - services for the diagnosis and treatment of those mental health or

psychiatric categories that are listed in the current edition of the International Classification of Diseases

section on Mental and Behavioral Disorders or the Diagnostic and Statistical Manual of the American

Psychiatric Association. The fact that a condition is listed in the current edition of the International

Classification of Diseases section on Mental and Behavioral Disorders or Diagnostic and Statistical

Manual of the American Psychiatric Association does not mean that treatment for the condition is a

Covered Health Care Service.

Mental Health/Substance-Related and Addictive Disorders Designee - the organization or individual,

designated by us, that provides or arranges Mental Health Care Services and Substance-Related and

Addictive Disorders Services.

Mental Illness - those mental health or psychiatric diagnostic categories that are listed in the current

edition of the International Classification of Diseases section on Mental and Behavioral Disorders or

Diagnostic and Statistical Manual of the American Psychiatric Association. The fact that a condition is

listed in the current edition of the International Classification of Diseases section on Mental and

Behavioral Disorders or Diagnostic and Statistical Manual of the American Psychiatric Association does

not mean that treatment for the condition is a Covered Health Care Service.

COC23.INS.2018.SG.ME

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. This does not include those providers who have agreed to discount their charges for

Covered Health Care Services. 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 Care Services, but not all

Covered Health Care 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 Care Services and products included in the

participation agreement and an out-of-Network provider for other Covered Health Care Services and

products. The participation status of providers will change from time to time.

Network Benefits - the description of how Benefits are paid for Covered Health Care Services provided

by Network providers. The Schedule of Benefits will tell you if your plan offers Network Benefits and how

Network Benefits apply.

New Pharmaceutical Product - a Pharmaceutical Product or new dosage form of a previously approved

Pharmaceutical Product. It applies to 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 ends on the earlier

of the following dates:

• The date as determined by us or our designee, which is based on when the Pharmaceutical

Product is reviewed and when utilization management strategies are implemented.

• December 31st of the following calendar year.

Non-Medical 24-Hour Withdrawal Management - an organized residential service, including those

defined in the American Society of Addiction Medicine (ASAM) Criteria, providing 24-hour supervision,

observation, and support for patients who are intoxicated or experiencing withdrawal, using peer and

social support rather than medical and nursing care.

Nurse - an individual who qualifies under the terminology in accordance with Maine statutes or

administrative rules of the licensing or registry board of the state.

Open Enrollment Period - a period of time, after the Initial Enrollment Period, when Eligible Persons

may enroll themselves and Dependents under the Policy. The Group sets the period of time that is the

Open Enrollment Period.

Out-of-Network Benefits - the description of how Benefits are paid for Covered Health Care Services

provided by out-of-Network providers. The Schedule of Benefits will tell you if your plan offers Out-of-

Network Benefits and how Out-of-Network Benefits apply.

Out-of-Pocket Limit - the maximum amount you pay every year. The Schedule of Benefits will tell you

how the Out-of-Pocket Limit applies.

Partial Hospitalization/Day Treatment - a structured ambulatory program. The program may be

freestanding or Hospital-based and provides services for at least 20 hours per week.

Pharmaceutical Product(s) - U.S. Food and Drug Administration (FDA) - approved prescription

medications or products administered in connection with a Covered Health Care Service by a Physician.

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, certified Nurse practitioner,

physician assistant, certified midwife, certified Nurse midwife, clinical social worker, certified social

worker, mental health services counseling professional, certified Nurse clinical specialist in psychiatric

and mental health nursing, registered Nurse first assistant, certified registered Nurse anesthetist,

ophthalmologist, acupuncturist, naturopath, independent practice dental hygienist, licensed clinical

professional counselor, marriage and family counselor, pastoral counselor (except when providing

services to a member of his or her church or congregation in the course of his or her duties as a pastor,

COC23.INS.2018.SG.ME

minister or staff person), 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 Group that includes all of the following:

• Group Policy.

• Certificate.

• Schedule of Benefits.

• Group Application.

• Riders.

• Amendments.

These documents make up the entire agreement that is issued to the Group.

Policy Charge - the sum of the Premiums for all Covered Persons enrolled under the Policy.

Pregnancy - includes all of the following:

• Prenatal care.

• Postnatal care.

• Childbirth.

• Any complications associated with Pregnancy.

Preimplantation Genetic Testing (PGT) - a test performed to analyze the DNA from oocytes or embryos

for human leukocyte antigen (HLA) typing or for determining genetic abnormalities. These include:

• PGT-M - for monogenic disorder (formerly single-gene PGD).

• PGT-SR - for structural rearrangements (formerly chromosomal PGD).

Premium - the periodic fee required for each Subscriber and each Enrolled Dependent, in accordance

with the terms of the Policy.

Presumptive Drug Test - test to determine the presence or absence of drugs or a drug class in which

the results are indicated as negative or positive result.

Primary Care Physician - a Physician who has a majority of his or her practice in general pediatrics,

internal medicine, obstetrics/gynecology, family practice or general medicine.

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:

• Services exceed the scope of Intermittent Care in the home.

• 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.

• 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.

Recognized Amount - the amount which Co-payment, Co-insurance and applicable deductible, is based

on for the below Covered Health Care Services when provided by out-of-Network providers:

• Out-of-Network Emergency Health Care Services.

COC23.INS.2018.SG.ME

• Non-Emergency Covered Health Care Services received at certain Network facilities by out-of-

Network Physicians, when such services are either Ancillary Services, or non-Ancillary Services

that have not satisfied the notice and consent criteria of section 2799B-2(d) of the Public Health

Service Act. For the purpose of this provision, "certain Network facilities" are limited to a hospital

(as defined in 1861(e) of the Social Security Act), a hospital outpatient department, a critical access

hospital (as defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center

described in section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the

Secretary.

The amount is based on one of the following in the order listed below as applicable:

1) An All Payer Model Agreement if adopted,

2) State law, or

3) The lesser of the qualifying payment amount as determined under applicable law, or the amount

billed by the provider or facility.

The Recognized Amount for Air Ambulance services provided by an out-of-Network provider will be

calculated based on the lesser of the qualifying payment amount as determined under applicable law or

the amount billed by the Air Ambulance service provider.

Note: Covered Health Care Services that use the Recognized Amount to determine your cost

sharing may be higher or lower than if cost sharing for these Covered Health Care Services were

determined based upon an Allowed Amount.

Remote Physiologic Monitoring - the automatic collection and electronic transmission of patient

physiologic data that are analyzed and used by a licensed Physician or other qualified health care

professional to develop and manage a treatment plan related to a chronic and/or acute health illness or

condition. The treatment plan will provide milestones for which progress will be tracked by one or more

Remote Physiologic Monitoring devices. Remote Physiologic Monitoring must be ordered by a licensed

Physician or other qualified health care professional who has examined the patient and with whom the

patient has an established, documented, and ongoing relationship. Remote Physiologic Monitoring may

not be used while the patient is inpatient at a Hospital or other facility. Use of multiple devices must be

coordinated by one Physician.

Residential Treatment - treatment in a facility established and operated as required by law, which

provides Mental Health Care Services or Substance-Related and Addictive Disorders Services. It must

meet all of the following requirements:

• Provides a program of treatment, approved by the Mental Health/Substance-Related and Addictive

Disorders Designee, under the active participation and direction of a Physician and, approved by

the Mental Health/Substance-Related and Addictive Disorder Designee.

• Offers organized treatment services that feature a planned and structured regimen of care in a 24-

hour setting and provides at least the following basic services:

▪ 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 Care Services not described in this

Certificate. Covered Health Care Services provided by a Rider may be subject to payment of additional

Premiums. (Note that Benefits for Outpatient Prescription Drugs, Pediatric Vision Care Services and

Pediatric Dental Services, while presented in Rider format, are not subject to payment of additional

Premiums and are included in the overall Premium for Benefits under the Policy.) Riders are effective only

COC23.INS.2018.SG.ME

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.

Secretary - as that term is applied in the No Surprises Act of the Consolidated Appropriations Act

(P.L.116-260).

Semi-private Room - a room with two or more beds. When an Inpatient Stay in a Semi-private Room is a

Covered Health Care Service, the difference in cost between a Semi-private Room and a private room is

a Benefit only when a private room is Medically Necessary, or when a Semi-private Room is not available.

Sickness - physical illness, disease or Pregnancy. The term Sickness as used in this Certificate includes

Mental Illness or substance-related and addictive disorders, regardless of the cause or origin of the

Mental Illness or substance-related and addictive disorder.

Skilled Care - skilled nursing, skilled teaching, skilled habilitation, and skilled rehabilitation services when

all of the following are true:

• 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.

• Ordered by a Physician.

• Not delivered for the purpose of helping with activities of daily living, including dressing, feeding,

bathing or transferring from a bed to a chair.

• Requires clinical training in order to be delivered safely and effectively.

• Not Custodial Care, which can safely and effectively be performed by trained non-medical

personnel.

Skilled Nursing Facility - a Hospital or nursing facility that is licensed and operated as required by law.

Specialist - 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.

Specialty Pharmaceutical Product - Pharmaceutical Products that are generally high cost,

biotechnology drugs used to treat patients with certain illnesses.

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 Group.

Substance-Related and Addictive Disorders Services - services for the diagnosis and treatment of

alcoholism and substance-related and addictive disorders that are listed in the current edition of the

International Classification of Diseases section on Mental and Behavioral Disorders or Diagnostic and

Statistical Manual of the American Psychiatric Association. The fact that a disorder is listed in the current

edition of the International Classification of Diseases section on Mental and Behavioral Disorders or

Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment

of the disorder is a Covered Health Care Service.

Surrogate - a female who becomes pregnant usually by artificial insemination or transfer of a fertilized

egg (embryo) for the purpose of carrying the fetus for another person.

Telehealth - the use of information technology and includes synchronous encounters, asynchronous

encounters, store and forward transfers and telemonitoring. "Store and forward transfers" means

transmission of an enrollee's recorded health history through a secure electronic system to a provider.

"Asynchronous encounters" means the interaction or consultation between an enrollee and the enrollee's

provider or between providers regarding the enrollee through a system with the ability to store digital

information, including, but not limited to, still images, video, audio and text files, and other relevant data in

one location and subsequently transmit such information for interpretation at a remote site by health

professionals without requiring the simultaneous presence of the patient or the health professionals.

"Synchronous encounters" means a real-time interaction conducted with interactive audio or video

connection between an enrollee and the enrollee's provider or between providers regarding the enrollee.

"Telemonitoring," as it pertains to the delivery of health care services, means the use of information

COC23.INS.2018.SG.ME

technology to remotely monitor an enrollee's health status via electronic means allowing the provider to

track the enrollee's health data over time. Telemonitoring may be synchronous or asynchronous.

Telehealth does not include virtual care services provided by a Designated Virtual Network Provider for

which Benefits are provided as described under Virtual Care Services.

Therapeutic, Adjustive and Manipulative Services - detection or correction (by manual or mechanical

means) of subluxation(s) in the body to remove nerve interference or its effects. The interference must be

the result of or related to distortion, misalignment or subluxation of, or in, the vertebral column.

Total Disability or Totally Disabled - a Subscriber's inability, as a result of covered Sickness or

Accident, to engage in any employment or occupation for which he or she becomes qualified by reason of

education, training or experience and is not engaged in any employment or occupation for wage or profit;

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 Living - Mental Health Care Services and Substance-Related and Addictive Disorders

Services provided through facilities, group homes and supervised apartments which provide 24-hour

supervision, including those defined in the American Society of Addiction Medicine (ASAM) Criteria, and

are either:

• Sober living arrangements such as drug-free housing or alcohol/drug halfway houses. They provide

stable and safe housing, an alcohol/drug-free environment and support for recovery. They may be

used as an addition to ambulatory treatment when it doesn't offer the intensity and structure

needed to help you with recovery.

• Supervised living arrangements which are residences such as facilities, group homes and

supervised apartments. They provide stable and safe housing and the opportunity to learn how to

manage activities of daily living. They may be used as an addition to treatment when it doesn't offer

the intensity and structure needed to help you with recovery.

Unproven Service(s) - services, including medications and devices, regardless of U.S. Food and Drug

Administration (FDA) approval, that are not determined to be effective for treatment of the medical

condition or not determined 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 care

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, as we determine, consider an otherwise Unproven Service to

be a Covered Health Care Service for that Sickness or condition. Prior to such a consideration, we

must first establish that there is sufficient evidence to conclude that, even though unproven, the

service has significant potential as an effective treatment for that Sickness or condition.

Urgent Care Center - a facility that provides Covered Health Care Services that are required to prevent

serious deterioration of your health. These services are required as a result of an unforeseen Sickness,

Injury, or the onset of sudden or severe symptoms.

COC23.INS.2018.SG.ME

Section 10: Travel and Lodging Program

The Travel and Lodging Program provides a Covered Person with a travel and lodging allowance related

to the Covered Health Care Service that is not available in the Covered Person's state of residence due to

law or regulation when such services are received in another state, as legally permissible.

This program provides an allowance for reasonable travel and lodging expenses for a Covered Person

and travel companion when the Covered Person must travel at least 50 miles from their address, as

reflected in our records, to receive the Covered Health Care Service.

This program provides an allowance for incurred reasonable travel and lodging expenses only and is

independent of any existing medical coverage available for the Covered Person. An allowance of up to

$2,000 per Covered Person per year will be provided for travel and lodging expenses incurred as a part of

the Covered Health Care Service. Lodging expenses are further limited to $50 per night for the Covered

Person, or $100 per night for the Covered Person with a travel companion.

Please remember to save travel and lodging receipts to submit for reimbursement. If you would like

additional information regarding the Travel and Lodging Program, you may contact us at www.myuhc.com

or the telephone number on your identification (ID) card.

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

UnitedHealthcare Choice Plus

UnitedHealthcare Insurance Company

Schedule of Benefits

How Do You Access Benefits?

Selecting a Network Primary Care Physician

You must select a Network Primary Care Physician who is located in the geographic area of the

permanent residence of the Subscriber. In general health care terminology, a Primary Care Physician

may also be referred to as a PCP. A Network Primary Care Physician will be able to coordinate all

Covered Health Care Services and promote continuity of care. If you are the custodial parent of an

Enrolled Dependent child, you must select a Network Primary Care Physician who is located in the

geographic area of the permanent residence of the Subscriber for that child.

You may designate a Network Physician who specializes in pediatrics (including pediatric subspecialties,

based on the scope of that provider's license under applicable state law) as the Network Primary Care

Physician for an Enrolled Dependent child. You do not need a referral from a Primary Care Physician and

may seek care directly from a Specialist, including a Physician who specializes in obstetrics or

gynecology.

You may change your Network Primary Care Physician by calling the telephone number shown on your

ID card or by going to www.myuhc.com. Changes are permitted once per month. Changes submitted on

or before the last day of the month will be effective on the first day of the following month.

You can choose to receive Network Benefits or Out-of-Network Benefits.

Network Benefits apply to Covered Health Care Services that are provided by a Network Physician or

other Network provider. You are not required to select a Primary Care Physician in order to obtain

Network Benefits.

Out-of-Network Benefits apply to Covered Health Care Services that are provided by an out-of-Network

Physician or other out-of-Network provider, or Covered Health Care Services that are provided at an out-

of-Network facility.

Emergency Health Care Services provided by an out-of-Network provider will be reimbursed as set forth

under Allowed Amounts as described at the end of this Schedule of Benefits.

Covered Health Care Services provided at certain Network facilities by an out-of-Network Physician,

when not Emergency Health Care Services, will be reimbursed as set forth under Allowed Amounts as

described at the end of this Schedule of Benefits. For these Covered Health Care Services, "certain

Network facility" is limited to a hospital (as defined in 1861(e) of the Social Security Act), a hospital

outpatient department, a critical access hospital (as defined in 1861(mm)(1) of the Social Security Act), an

ambulatory surgical center as described in section 1833(i)(1)(A) of the Social Security Act, and any other

facility specified by the Secretary.

Ground and Air Ambulance transport provided by an out-of-Network provider will be reimbursed as set

forth under Allowed Amounts as described at the end of this Schedule of Benefits.

Depending on the geographic area and the service you receive, you may have access through our

Shared Savings Program to out-of-Network providers who have agreed to discount their billed charges for

Covered Health Care Services. Refer to the definition of Shared Savings Program in Section 9: Defined

Terms of the Certificate for details about how the Shared Savings Program applies.

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

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 Group,

this Schedule of Benefits will control.

Does Prior Authorization Apply?

We require prior authorization for certain Covered Health Care Services. Network providers are

responsible for obtaining prior authorization before they provide these services to you.

We recommend that you confirm with us that all Covered Health Care Services have been prior

authorized as required. Before receiving these services from a Network provider, you may want to call 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 do not prior authorize as required. You can call us at the telephone number on your ID card.

When you choose to receive certain Covered Health Care Services from out-of-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 an out-of-Network provider

intends to admit you to a Network facility or to an out-of-Network facility or refers you to other

Network or out-of-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. Services for which you are

required to obtain prior authorization are shown in the Schedule of Benefits table within each

Covered Health Care Service category.

To obtain prior authorization, call the telephone number 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.

Please note that prior authorization timelines apply. Refer to the applicable Benefit description in

the Schedule of Benefits table to find out how far in advance you must obtain prior authorization.

For Covered Health Care Services that do not require you to obtain prior authorization, when you choose

to receive services from out-of-Network providers, we urge you to confirm with us that the services you

plan to receive are Covered Health Care 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 Care

Service, and therefore are excluded. In other instances, the same procedure may meet the definition of

Covered Health Care Services. By calling before you receive treatment, you can check to see if the

service is subject to limitations or exclusions.

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

received, our final coverage determination will be changed to account for those differences, and we will

only pay Benefits based on the services delivered to you.

If you choose to receive a service that has been determined not to be a Medically Necessary Covered

Health Care Service, you will be responsible for paying all charges and no Benefits will be paid.

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

Care Management

When you seek prior authorization as required, we will work with you to put in place 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 Care Services.

What Will You Pay for Covered Health Care Services?

Benefits for Covered Health Care Services are described in the tables below.

Annual Deductibles are calculated on a year basis.

Out-of-Pocket Limits are calculated on a year basis.

When Benefit limits apply, the limit stated refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Benefit limits are calculated on a year basis unless otherwise specifically stated.

Payment Term And Description

Amounts

Annual Deductible

The amount you pay for Covered Health Care Services per year

before you are eligible to receive Benefits. Benefits for

outpatient prescription drugs on the List of Preventive

Medications are not subject to payment of the Annual

Deductible.

Coupons: We may not permit certain coupons or offers from

pharmaceutical manufacturers or an affiliate to apply to your

Annual Deductible.

Amounts paid toward the Annual Deductible for Covered Health

Care 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 the Allowed Amount or the

Recognized Amount when applicable. The Annual Deductible

does not include any amount that exceeds the Allowed Amount.

Details about the way in which Allowed Amounts are

determined appear at the end of the Schedule of Benefits table.

The Annual Deductible does not include any charges for non-

Covered Health Care Services.

Network

$1,500 per Covered Person, not to

exceed $3,000 for all Covered Persons

in a family.

Out-of-Network

$10,000 per Covered Person, not to

exceed $20,000 for all Covered

Persons in a family.

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

Payment Term And Description

Amounts

Out-of-Pocket Limit

The maximum you pay per year for the Annual Deductible, Co-

payments or Co-insurance. Once you reach the Out-of-Pocket

Limit, Benefits are payable at 100% of Allowed Amounts during

the rest of that year.

Details about the way in which Allowed Amounts are

determined appear at the end of the Schedule of Benefits table.

The Out-of-Pocket Limit does not include any of the following

and, once the Out-of-Pocket Limit has been reached, you still

will be required to pay the following:

• Any charges for non-Covered Health Care Services.

• The amount you are required to pay if you do not obtain

prior authorization as required.

• Charges that exceed Allowed Amounts, when applicable.

Coupons: We may not permit certain coupons or offers from

pharmaceutical manufacturers or an affiliate to apply to your

Out-of-Pocket Limit.

Network

$6,000 per Covered Person, not to

exceed $12,000 for all Covered

Persons in a family.

The Out-of-Pocket Limit includes the

Annual Deductible.

Out-of-Network

$20,000 per Covered Person, not to

exceed $40,000 for all Covered

Persons in a family.

The Out-of-Pocket Limit includes the

Annual Deductible.

Co-payment

Co-payment is the amount you pay (calculated as a set dollar amount) each time you receive certain

Covered Health Care Services. When Co-payments apply, the amount is listed on the following pages

next to the description for each Covered Health Care Service.

Please note that for Covered Health Care Services, you are responsible for paying the lesser of:

• The applicable Co-payment.

• The Allowed Amount or the Recognized Amount when applicable.

Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of

Benefits table.

Co-insurance

Co-insurance is the amount you pay (calculated as a percentage of the Allowed Amount or the

Recognized Amount when applicable) each time you receive certain Covered Health Care Services.

Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of

Benefits table.

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

1. Ambulance Services

Prior Authorization Requirement

In most cases, we will initiate and direct non-Emergency ambulance transportation.

For Out-of-Network Benefits, if you are requesting non-Emergency Air Ambulance services (including any

affiliated non-Emergency ground ambulance transport in conjunction with non-Emergency Air Ambulance

transport), you must obtain authorization as soon as possible before transport. If you do not obtain prior

authorization as required, the amount you are required to pay will be increased to 50% of the Allowed

Amount, however the amount of the increase will not exceed $500.

Emergency Ambulance

Allowed Amounts for ground

and Air Ambulance transport

provided by an out-of-

Network provider will be

determined as described

below under Allowed

Amounts in this Schedule of

Benefits.

Network

Ground Ambulance

30%

Air Ambulance

30%

Yes

Out-of-Network

Same as Network

Non-Emergency

Ambulance

Ground or Air Ambulance, as

we determine appropriate.

Allowed Amounts for Air

Ambulance transport

provided by an out-of-

Network provider will be

determined as described

below under Allowed

Amounts in this Schedule of

Benefits.

Network

Ground Ambulance

30%

Air Ambulance

30%

Yes

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

Out-of-Network

Ground Ambulance

50%

Air Ambulance

Same as Network

Yes

Same as Network

Yes

Same as Network

2. Autism Spectrum Disorder Treatment

Network

$30 per visit

Yes

Out-of-Network

20%

Yes

3. Cellular and Gene

Therapy

Prior Authorization Requirement

For Out-of-Network Benefits, you must obtain prior authorization as soon as the possibility of a Cellular or

Gene Therapy arises. If you do not obtain prior authorization as required, the amount you are required to

pay will be increased to 50% of the Allowed Amount, however the amount of the increase will not exceed

$500.

In addition, for Out-of-Network Benefits, you must contact us 24 hours before admission for scheduled

admissions or as soon as is reasonably possible for non-scheduled admissions.

For Network Benefits, Cellular

or Gene Therapy services must

be received from a Designated

Provider.

Network

Depending upon where the Covered Health Care Service is provided,

Benefits will be the same as those stated under each Covered Health

Care Service category in this Schedule of Benefits.

Out-of-Network

Depending upon where the Covered Health Care Service is provided,

Benefits will be the same as those stated under each Covered Health

Care Service category in this Schedule of Benefits.

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

4. Children's Early

Intervention Services

Network

Depending upon where the Covered Health Care Service is provided,

Benefits will be the same as those stated under each Covered Health

Care Service category in this Schedule of Benefits.

Out-of-Network

Depending upon where the Covered Health Care Service is provided,

Benefits will be the same as those stated under each Covered Health

Care Service category in this Schedule of Benefits.

5. Clinical Trials

Prior Authorization Requirement

For Out-of-Network Benefits, you must obtain prior authorization as soon as the possibility of participation

in a clinical trial arises. If you do not obtain prior authorization as required, the amount you are required to

pay will be increased to 50% of the Allowed Amount, however the amount of the increase will not exceed

$500.

Depending upon the Covered Health

Care 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 Care Service is

provided, Benefits will be the same as those stated under each

Covered Health Care Service category in this Schedule of

Benefits.

Out-of-Network

Depending upon where the Covered Health Care Service is

provided, Benefits will be the same as those stated under each

Covered Health Care Service category in this Schedule of

Benefits.

6. Congenital Heart Disease (CHD) Surgeries

Prior Authorization Requirement

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

For Out-of-Network Benefits, you must obtain prior authorization as soon as the possibility of a CHD

surgery arises. If you do not obtain prior authorization as required, the amount you are required to pay will

be increased to 50% of the Allowed Amount, however the amount of the increase will not exceed $500.

It is important that you notify us regarding your intention to have surgery. Your notification will

open the opportunity to become enrolled in programs that are designed to achieve the best

outcomes for you.

Benefits under this section include only

the inpatient facility charges for the

CHD surgery. Depending upon where

the Covered Health Care 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 Care Service

category in this Schedule of Benefits.

Network

Benefits will be the same as stated under Hospital - Inpatient

Stay in this Schedule of Benefits.

Out-of-Network

Benefits will be the same as stated under Hospital - Inpatient

Stay in this Schedule of Benefits.

7. Dental Anesthesia

Services

Prior Authorization Requirement

For Network and Out-of-Network Benefits you must obtain prior authorization five business days before

receiving services or as soon as is reasonably possible. If you do not obtain prior authorization as

required, the amount you are required to pay will be increased to 50% of the Allowed Amount, however

the amount of the increase will not exceed $500

Network

Depending upon where the Covered Health Care Service is provided,

Benefits will be the same as those stated under each Covered Health

Care Service category in this Schedule of Benefits.

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

100

When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

Out-of-Network

Depending upon where the Covered Health Care Service is provided,

Benefits will be the same as those stated under each Covered Health

Care Service category in this Schedule of Benefits.

8. Dental Services - Accident Only

Network

30%

Yes

Out-of-Network

Same as Network

9. Diabetes Services

Prior Authorization Requirement

For Out-of-Network Benefits, you must obtain prior authorization before obtaining any DME for the

management and treatment of diabetes that costs more than $1,000 (either retail purchase cost or

cumulative retail rental cost of a single item). If you do not obtain prior authorization as required, the

amount you are required to pay will be increased to 50% of the Allowed Amount, however the amount of

the increase will not exceed $500.

Diabetes Self-Management and

Training/Diabetic Eye Exams/Foot

Care

Services under this category include

but are not limited to the following.

Please refer to your Certificate for

details.

• Foot care for systemic

circulatory disease.

• Nutritional therapy.

Network

Depending upon where the Covered Health Care Service is

provided, Benefits for diabetes self-management and

training/diabetic eye exams/foot care will be the same as those

stated under each Covered Health Care Service category in this

Schedule of Benefits.

Out-of-Network

Depending upon where the Covered Health Care Service is

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

101

When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

provided, Benefits for diabetes self-management and

training/diabetic eye exams/foot care will be the same as those

stated under each Covered Health Care Service category in this

Schedule of Benefits.

Diabetes Self-Management Items

Benefits for diabetes equipment that

meets the definition of DME are not

subject to the limit stated under

Durable Medical Equipment (DME),

Orthotics and Supplies.

Network

Depending upon where the Covered Health Care Service is

provided, Benefits for diabetes self-management items will be the

same as those stated under Durable Medical Equipment (DME),

Orthotics and Supplies and in the Outpatient Prescription Drug

Rider.

Out-of-Network

Depending upon where the Covered Health Care Service is

provided, Benefits for diabetes self-management items will be the

same as those stated under Durable Medical Equipment (DME),

Orthotics and Supplies and in the Outpatient Prescription Drug

Rider.

10. Durable Medical Equipment (DME), Orthotics and

Supplies

Prior Authorization Requirement

For Out-of-Network Benefits, you must obtain prior authorization before obtaining any DME or orthotic

that costs more than $1,000 (either retail purchase cost or cumulative retail rental cost of a single item). If

you do not obtain prior authorization as required, the amount you are required to pay will be increased to

50% of the Allowed Amount, however the amount of the increase will not exceed $500.

To receive Network Benefits, you must

obtain the DME or orthotic from the

vendor we identify or from the

prescribing Network Physician.

Network

30%

Yes

Out-of-Network

50%

Yes

11. Emergency Health Care Services - Outpatient

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

102

When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

Note: If you are confined in an out-of-

Network Hospital after you receive

outpatient Emergency Health Care

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 knowingly

elect to stay in the out-of-Network

Hospital after the date we decide a

transfer is medically appropriate,

Network Benefits will not be provided.

Out-of-Network Benefits may be

available if the continued stay is

determined to be a Covered Health

Care Service.

If you are admitted as an inpatient to a

Hospital directly from the Emergency

room, the Benefits provided as

described under Hospital - Inpatient

Stay will apply. You will not have to

pay the Emergency Health Care

Services Co-payment, Co-insurance

and/or deductible.

Allowed Amounts for Emergency

Health Care Services provided by an

out-of-Network provider will be

determined as described below under

Allowed Amounts in this Schedule of

Benefits.

Network

$500 per visit.

Yes

Out-of-Network

Same as Network

12. Enteral Nutrition

Network

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

103

When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

30%

Yes

Out-of-Network

50%

Yes

13. Family Planning

Network

Depending upon where the Covered Health Care Service is provided,

Benefits will be the same as those stated under each Covered Health

Care Service category in this Schedule of Benefits.

Out-of-Network

Depending upon where the Covered Health Care Service is provided,

Benefits will be the same as those stated under each Covered Health

Care Service category in this Schedule of Benefits.

14. Fertility Preservation for Iatrogenic Infertility

Prior Authorization Requirement

For Out-of-Network Benefits, you must obtain prior authorization as soon as possible. If you do not obtain

prior authorization as required, the amount you are required to pay will be increased to 50% of the

Allowed Amount, however the amount of the increase will not exceed $500.

Limited to $20,000 per Covered

Person during the entire period of time

he or she is enrolled for coverage

under the Policy. This Benefit limit will

be the same as and combined with

those stated under Preimplantation

Genetic Testing (PGT) and Related

Services. Benefits are further limited to

one cycle of fertility preservation for

Iatrogenic Infertility per Covered

Person during the entire period of time

he or she is enrolled for coverage

under the Policy.

Network

30%

Yes

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

104

When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

Out-of-Network

50%

Yes

15. Gender Dysphoria

Prior Authorization Requirement for Surgical Treatment

For Out-of-Network Benefits, you must obtain prior authorization as soon as the possibility of surgery

arises. If you do not obtain prior authorization as required, the amount you are required to pay will be

increased to 50% of the Allowed Amount, however the amount of the increase will not exceed $500.

In addition, for Out-of-Network Benefits, you must contact us 24 hours before admission for an Inpatient

Stay.

It is important that you notify us as soon as the possibility of surgery arises. Your notification

allows the opportunity for us to provide you with additional information and services that may be

available to you and are designed to achieve the best outcomes for you.

Prior Authorization Requirement for Non-Surgical Treatment

Depending upon where the Covered Health Care Service is provided, any applicable prior authorization

requirements will be the same as those stated under each Covered Health Care Service category in this

Schedule of Benefits.

Network

Depending upon where the Covered Health Care Service is

provided, Benefits will be the same as those stated under each

Covered Health Care Service category in this Schedule of

Benefits and in the Outpatient Prescription Drug Rider.

Out-of-Network

Depending upon where the Covered Health Care Service is

provided, Benefits will be the same as those stated under each

Covered Health Care Service category in this Schedule of

Benefits and in the Outpatient Prescription Drug Rider.

16. Habilitative Services

Prior Authorization Requirement

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

105

When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

For Out-of-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 do not

obtain prior authorization as required, the amount you are required to pay will be increased to 50% of the

Allowed Amount, however the amount of the increase will not exceed $500.

In addition, for Out-of-Network Benefits, you must contact us 24 hours before admission for scheduled

admissions or as soon as is reasonably possible for non-scheduled admissions.

Habilitative services received during

an Inpatient Stay in an Inpatient

Rehabilitative Facility or Skilled

Nursing Facility are limited to 150 days

per year.

Network

Inpatient

Depending upon where the Covered Health Care Service is

provided, Benefits will be the same as those stated under each

Covered Health Care Service category in this Schedule of Benefit

Outpatient therapies are limited per

year as follows:

• 60 visits for any combination of

physical therapy, occupational

therapy and speech therapy.

• 30 visits of post-cochlear

implant aural therapy.

• 20 visits of cognitive therapy.

Benefits for physical therapy,

occupational therapy and speech

therapy are unlimited for Autism

Spectrum Disorder.

Outpatient

$30 per visit

Yes

Out-of-Network

Inpatient

Depending upon where the Covered Health Care Service is

provided, Benefits will be the same as those stated under each

Covered Health Care Service category in this Schedule of

Benefits.

Outpatient

Yes

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

106

When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

20%

17. Hearing Aids

Limited to a single purchase per

hearing impaired ear every 36 months.

Repair and/or replacement of a

hearing aid would apply to this limit in

the same manner as a purchase.

Network

30%

Yes

Out-of-Network

50%

Yes

18. Home Health Care

Prior Authorization Requirement

For Out-of-Network Benefits, you must obtain prior authorization five business days before receiving

services or as soon as is reasonably possible. If you do not obtain prior authorization as required, the

amount you are required to pay will be increased to 50% of the Allowed Amount, however the amount of

the increase will not exceed $500.

Services under this category include

but are not limited to the following.

Please refer to your Certificate for

coverage details.

• Inhalation therapy.

To receive Network Benefits for the

administration of intravenous infusion,

you must receive services from a

provider we identify.

Network

30%

Yes

Out-of-Network

50%

Yes

19. Hospice Care

Prior Authorization Requirement

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

107

When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

For Out-of-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 do not obtain prior

authorization as required, the amount you are required to pay will be increased to 50% of the Allowed

Amount, however the amount of the increase will not exceed $500.

In addition, for Out-of-Network Benefits, you must contact us within 24 hours of admission for an Inpatient

Stay in a hospice facility.

Services under this category include

but are not limited to the following.

Please refer to your Certificate for

coverage details.

• Hospice respite care.

• Nutritional counseling.

Network

30%

Yes

Out-of-Network

50%

Yes

20. Hospital - Inpatient Stay

Prior Authorization Requirement

For Out-of-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 do not

obtain prior authorization as required, the amount you are required to pay will be increased to 50% of the

Allowed Amount, however the amount of the increase will not exceed $500.

In addition, for Out-of-Network Benefits, you must contact us 24 hours before admission for scheduled

admissions or as soon as is reasonably possible for non-scheduled admissions.

Services under this category include

but are not limited to the following.

Please refer to your Certificate for

coverage details.

• Inhalation therapy.

Network

30%

Yes

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

108

When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

Out-of-Network

50%

Yes

21. Infant Formulas

Prior Authorization Requirement

For Out-of-Network Benefits you must obtain prior authorization five business days before obtaining the

formula or as soon as is reasonably possible. If you do not obtain prior authorization as required, the

amount you are required to pay will be increased to 50% of the Allowed Amount, however the amount of

the increase will not exceed $500

Network

30%

As stated under the

Outpatient Prescription

Drug Rider

Yes

Out-of-Network

50%

As stated under the

Outpatient Prescription

Drug Rider

Yes

22. Lab, X-Ray and Diagnostic - Outpatient

Prior Authorization Requirement

For Out-of-Network Benefits for Genetic Testing, sleep studies, stress echocardiography and

transthoracic echocardiogram, you must obtain prior authorization five business days before scheduled

services are received. If you do not obtain prior authorization as required, the amount you are required to

pay will be increased to 50% of the Allowed Amount, however the amount of the increase will not exceed

$500.

Lab Testing - Outpatient

Network

30%

Yes

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

109

When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

Out-of-Network

50%

Yes

Human Leukocyte Antigen Testing

Network

None up to the first $150

of the Allowed Amount;

then covered as stated

in Lab Testing -

Outpatient

Yes

Out-of-Network

50%

Yes

Prostate-Specific Antigen Testing

Network

None

Yes

Out-of-Network

50%

Yes

X-Ray and Other Diagnostic Testing

- Outpatient

Network

30%

Yes

Out-of-Network

50%

Yes

23. Major Diagnostic and Imaging - Outpatient

Prior Authorization Requirement

For Out-of-Network Benefits for CT, PET scans, MRI, MRA, and nuclear medicine, including nuclear

cardiology, 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 do

not obtain prior authorization as required, the amount you are required to pay will be increased to 50% of

the Allowed Amount, however the amount of the increase will not exceed $500.

Network

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

110

When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

30%

Yes

Out-of-Network

50%

Yes

24. Medical Foods

Prior Authorization Requirement

For Out-of-Network Benefits you must obtain prior authorization five business days before obtaining the

medical foods or as soon as is reasonably possible. If you do not obtain prior authorization as required,

the amount you are required to pay will be increased to 50% of the Allowed Amount, however the amount

of the increase will not exceed $500

Network

30%

As stated under the

Outpatient Prescription

Drug Rider

Yes

Out-of-Network

50%

As stated under the

Outpatient Prescription

Drug Rider

Yes

25. Mental Health Care and Substance-Related and

Addictive Disorders Services

Prior Authorization Requirement

For Out-of-Network Benefits for a scheduled admission for Mental Health Care and Substance-Related

and Addictive Disorders Services (including an admission for services at a Residential Treatment facility),

you must obtain prior authorization five business days before admission, or as soon as is reasonably

possible for non-scheduled admissions.

In addition, for Out-of-Network Benefits, you must obtain prior authorization before the following services

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

111

When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

are received: Partial Hospitalization/Day Treatment; Intensive Outpatient Treatment programs; outpatient

electro-convulsive treatment; psychological testing; transcranial magnetic stimulation; Intensive

Behavioral Therapy, including Applied Behavior Analysis (ABA).

If you do not obtain prior authorization as required, the amount you are required to pay will be increased

to 50% of the Allowed Amount, however the amount of the increase will not exceed $500.

Services under this category include

but are not limited to the following.

Please refer to your Certificate for

coverage details.

• Detoxification.

Network

Inpatient

30%

Outpatient

None for the first visit in

a year; $NaN for any

subsequent visits in that

year

30% for Partial

Hospitalization/Intensive

Outpatient Treatment

Yes

No, for the first

visit in a year

No, for any

subsequent visit in

a year but Co-

payment will apply

towards the

Annual Deductible

Yes

Out-of-Network

Inpatient

50%

Outpatient

50% for Partial

Hospitalization/Intensive

Yes

null

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

112

When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

Outpatient Treatment

Yes

26. Obesity - Weight Loss Surgery

Prior Authorization Requirement

For Out-of-Network Benefits, you must obtain prior authorization six months prior to surgery or as soon as

the possibility of obesity-weight loss surgery arises. If you do not obtain prior authorization as required,

the amount you are required to pay will be increased to 50% of the Allowed Amount, however the amount

of the increase will not exceed $500.

In addition, for Out-of-Network Benefits, you must contact us 24 hours before admission for an Inpatient

Stay.

It is important that you notify us regarding your intention to have surgery. Your notification will

open the opportunity to become enrolled in programs that are designed to achieve the best

outcomes for you.

Network

30%

Yes

Out-of-Network

50%

Yes

27. Ostomy Supplies

Limited to $2,500 per year.

Network

30%

Yes

Out-of-Network

50%

Yes

28. Parenteral and Enteral Therapy

Network

30%

Yes

Out-of-Network

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

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When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

50%

Yes

29. Pharmaceutical Products - Outpatient

Network

30%

Yes

Out-of-Network

50%

Yes

30. Physician Fees for Surgical and Medical Services

Covered Health Care Services

provided by an out-of-Network

Physician in certain Network facilities

will apply the same cost sharing (Co-

payment, Co-insurance and applicable

deductible) as if those services were

provided by a Network provider;

however, Allowed Amounts will be

determined as described below under

Allowed Amounts in this Schedule of

Benefits.

Network

30%

Yes

Out-of-Network

50%

Yes

31. Physician's Office Services - Sickness and Injury

Services under this category include

but are not limited to the following.

Please refer to your Certificate for

coverage details.

• Prostate cancer screening.

• Allergy testing.

Network

None for the first visit in

a year; $NaN for any

subsequent visits in that

year for a Primary Care

Physician office visit;

$70 for a Specialist

office visit

Yes

No, for the first

visit in a year

No, for any

subsequent visit in

a year but Co-

payment will

apply towards the

Annual Deductible

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

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When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

Out-of-Network

Yes

null

32. Pregnancy - Maternity Services

Prior Authorization Requirement

For Out-of-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 do not obtain prior authorization as required, the amount you

are required to pay will be increased to 50% of the Allowed Amount, however the amount of the increase

will not exceed $500.

Network

Benefits will be the same as those stated under each Covered

Health Care 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.

Out-of-Network

Benefits will be the same as those stated under each Covered

Health Care 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.

33. Preimplantation Genetic Testing (PGT) and Related

Services

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When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

Prior Authorization Requirement

For Out-of-Network Benefits, you must obtain prior authorization as soon as possible. If you do not obtain

prior authorization as required, the amount you are required to pay will be increased to 50% of the

Allowed Amount, however the amount of the increase will not exceed $500.

Benefit limits for related services will

be the same as, and combined with,

those stated under Fertility

Preservation for Iatrogenic Infertility.

This limit does not include

Preimplantation Genetic Testing (PGT)

for the specific genetic disorder.

This limit includes Benefits for ovarian

stimulation medications provided

under the Outpatient Prescription Drug

Rider.

Network

30%

Yes

Out-of-Network

50%

Yes

34. Preventive Care Services

Physician office services

Services under this category include

but are not limited to the following.

Please refer to your Certificate for

coverage details.

• Mammogram screening.

• Annual gynecological exam.

• Pap test.

Network

None

Yes

Out-of-Network

20%

Yes

Lab, X-ray or other preventive tests

Network

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

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When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

None

Yes

Out-of-Network

20%

Yes

Breast pumps

Network

None

Yes

Out-of-Network

20%

Yes

35. Prosthetic Devices

Prior Authorization Requirement

For Out-of-Network Benefits, you must obtain prior authorization before obtaining prosthetic devices that

exceed $1,000 in cost per device. If you do not obtain prior authorization as required, the amount you are

required to pay will be increased to 50% of the Allowed Amount, however the amount of the increase will

not exceed $500.

Network

20% for prosthetic

devices to replace an

arm or leg and 30% for

all other prosthetic

devices

Yes

Out-of-Network

50%

Yes

36. Reconstructive Procedures

Prior Authorization Requirement

For Out-of-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 do not obtain prior authorization as required, the amount you are

required to pay will be increased to 50% of the Allowed Amount, however the amount of the increase will

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

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When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

not exceed $500.

In addition, for Out-of-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.

Services under this category include

but are not limited to the following.

Please refer to your Certificate for

coverage details.

• Breast reduction.

• Varicose veins (symptomatic).

• Reconstructive services for birth

defects.

Network

Depending upon where the Covered Health Care Service is

provided, Benefits will be the same as those stated under each

Covered Health Care Service category in this Schedule of

Benefits.

Out-of-Network

Depending upon where the Covered Health Care Service is

provided, Benefits will be the same as those stated under each

Covered Health Care Service category in this Schedule of

Benefits.

37. Rehabilitation Services - Outpatient Therapy

Services under this category include

but are not limited to the following.

Please refer to your Certificate for

coverage details.

• Inhalation therapy.

• Massage therapy.

Limited per year as follows:

• 60 visits for any combination of

physical therapy, occupational

therapy and speech therapy.

• 30 visits of post-cochlear

implant aural therapy.

Network

$30 per visit

Yes

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When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

• 20 visits of cognitive

rehabilitation therapy.

Out-of-Network

20%

Yes

38. Scopic Procedures - Outpatient Diagnostic and

Therapeutic

Services under this category include

but are not limited to the following.

Please refer to your Certificate for

coverage details.

• Colorectal cancer screening.

Network

30%

Yes

Out-of-Network

50%

Yes

39. Skilled Nursing Facility/Inpatient Rehabilitation Facility

Services

Prior Authorization Requirement

For Out-of-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 do not

obtain prior authorization as required, the amount you are required to pay will be increased to 50% of the

Allowed Amount, however the amount of the increase will not exceed $500.

In addition, for Out-of-Network Benefits, you must contact us 24 hours before admission for scheduled

admissions or as soon as is reasonably possible for non-scheduled admissions.

Limited to 150 days per year.

Network

30%

Yes

Out-of-Network

50%

Yes

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

119

When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

40. Smoking Cessation

Limited to:

• 2 Physician Office Visits

per calendar year.

• Up to $35 per Smoking

Cessation Program.

Network

Depending upon where the Covered Health Care Service is provided,

Benefits will be the same as those stated under each Covered Health

Care Service category in this Schedule of Benefits.

Out-of-Network

Depending upon where the Covered Health Care Service is provided,

Benefits will be the same as those stated under each Covered Health

Care Service category in this Schedule of Benefits.

41. Surgery - Outpatient

Prior Authorization Requirement

For Out-of-Network Benefits for cardiac catheterization, pacemaker insertion, implantable cardioverter

defibrillators, 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 do not obtain

prior authorization as required, the amount you are required to pay will be increased to 50% of the

Allowed Amount, however the amount of the increase will not exceed $500.

Services under this category include

but are not limited to the following.

Please refer to your Certificate for

coverage details.

• Ambulatory surgery centers.

• Blood transfusions.

Network

30%

Yes

Out-of-Network

50%

Yes

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

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When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

42. Therapeutic, Adjustive and Manipulative Services

The below limits apply separately,

when applicable, for rehabilitative and

habilitative services.

Any combination of Network and Out-

of-Network Benefits for therapeutic,

adjustive and manipulative services is

limited to 40 visits per year.

Network

$30 per visit

Yes

Out-of-Network

20%

Yes

43. Therapeutic Treatments - Outpatient

Prior Authorization Requirement

For Out-of-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 do not obtain prior

authorization as required, the amount you are required to pay will be increased to 50% of the Allowed

Amount, however the amount of the increase will not exceed $500.

Services under this category include

but are not limited to the following.

Please refer to your Certificate for

coverage details.

• Chemotherapy.

• Infusion therapy.

• Colorectal cancer screening.

Network

30%

Yes

Out-of-Network

50%

Yes

44. Transplantation Services

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When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

Prior Authorization Requirement

For Out-of-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 do

not obtain prior authorization as required, the amount you are required to pay will be increased to 50% of

the Allowed Amount, however the amount of the increase will not exceed $500.

In addition, for Out-of-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).

Services under this category include

but are not limited to the following.

Please refer to your Certificate for

coverage details.

• Organ/tissue transplants.

For Network Benefits, transplantation

services must be received from a

Designated Provider. We do not

require that cornea transplants be

received from a Designated Provider in

order for you to receive Network

Benefits.

Network

Depending upon where the Covered Health Care Service is

provided, Benefits will be the same as those stated under each

Covered Health Care Service category in this Schedule of

Benefits.

Out-of-Network

Depending upon where the Covered Health Care Service is

provided, Benefits will be the same as those stated under each

Covered Health Care Service category in this Schedule of

Benefits.

45. Urgent Care Center Services

Co-payment/Co-insurance and any

deductible for the following services

also apply when the Covered Health

Care Service is performed at an

Urgent Care Center:

• Lab, radiology/X-rays and other

diagnostic services described

Network

$70 per visit

Yes

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

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When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

under Lab, X-Ray and

Diagnostic -Outpatient.

• Major diagnostic and nuclear

medicine described under Major

Diagnostic and Imaging -

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.

Out-of-Network

20%

Yes

46. Urinary Catheters

Network

30%

Yes

Out-of-Network

50%

Yes

47. Virtual Care Services

Network Benefits are available only

Network

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When Benefit limits apply, the limit refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Amounts or, for specific Covered Health Care Services as described in the definition of

Recognized Amount in the Certificate, Recognized Amounts. The Allowed Amounts provision near

the end of this Schedule of Benefits will tell you when you are responsible for amounts that

exceed the Allowed Amount.

Covered Health Care Service

What Is the Co-

payment or Co-

insurance You Pay?

This May Include a Co-

payment, Co-insurance

or Both.

Does the Amount

You Pay Apply to

the Out-of-

Pocket Limit?

Does the Annual

Deductible

Apply?

when services are delivered through a

Designated Virtual Network Provider.

You can find a Designated Virtual

Network Provider by contacting us at

www.myuhc.com or the telephone

number on your ID card.

None

Yes

Out-of-Network

20%

Yes

48. Vision Correction after

Surgery or Accident

Network

Benefits will be the same as those stated under the Durable Medical

Equipment category in this Schedule of Benefits.

Out-of-Network

Benefits will be the same as those stated under the Durable Medical

Equipment category in this Schedule of Benefits.

Allowed Amounts

Allowed Amounts are the amount we determine that we will pay for Benefits.

• For Network Benefits for Covered Health Care Services provided by a Network provider, except for

your cost sharing obligations, you are not responsible for any difference between Allowed Amounts

and the amount the provider bills.

• For Out-of-Network Benefits, except as described below, you are responsible for paying, directly to

the out-of-Network provider, any difference between the amount the provider bills you and the

amount we will pay for Allowed Amounts.

▪ For Covered Health Care Services that are Ancillary Services received at certain

Network facilities on a non-Emergency basis from out-of-Network Physicians, you are

not responsible, and the out-of-Network provider may not bill you, for amounts in excess of

your Co-payment, Co-insurance, or deductible which is based on the Recognized Amount as

defined in the Certificate.

▪ For Covered Health Care Services that are non-Ancillary Services received at certain

Network facilities on a non-Emergency basis from out-of-Network Physicians who

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124

have not satisfied the notice and consent criteria or for unforeseen or urgent medical

needs that arise at the time a non-Ancillary Service is provided for which notice and

consent has been satisfied as described below, you are not responsible, and the out-of-

Network provider may not bill you, for amounts in excess of your Co-payment, Co-insurance,

or deductible which is based on the Recognized Amount as defined in the Certificate.

▪ For Covered Health Care Services that are Emergency Health Care Services provided by

an out-of-Network provider, you are not responsible, and the out-of-Network provider may

not bill you, for amounts in excess of your applicable Co-payment, Co-insurance, or

deductible which is based on the Recognized Amount as defined in the Certificate.

▪ For Covered Health Care Services that are Air Ambulance services provided by an out-

of-Network provider, you are not responsible, and the out-of-Network provider may not bill

you, for amounts in excess of your applicable Co-payment, Co-insurance, or deductible

which is based on the rates that would apply if the service was provided by a Network

provider which is based on the Recognized Amount as defined in the Certificate.

Allowed Amounts are determined in accordance with our reimbursement policy guidelines or as required

by law, as described in the Certificate. You may determine the maximum allowable charge permitted for a

specific service by calling the telephone number on your ID card.

Network Benefits

Allowed Amounts are based on the following:

• When Covered Health Care Services are received from a Network provider, Allowed Amounts are

our contracted fee(s) with that provider.

• When Covered Health Care Services are received from an out-of-Network provider as arranged by

us, including when there is no Network provider who is reasonably accessible or available to

provide Covered Health Care Services, Allowed Amounts are an amount negotiated by us or an

amount permitted by law. Please contact us if you are billed for amounts in excess of your

applicable Co-insurance, Co-payment, or any deductible. We will not pay excessive charges or

amounts you are not legally obligated to pay.

Out-of-Network Benefits

When Covered Health Care Services are received from an out-of-Network provider as described

below, Allowed Amounts are determined as follows:

• For non-Emergency Covered Health Care Services received at certain Network facilities

from out-of-Network Physicians when such services are either Ancillary Services, or non-

Ancillary Services that have not satisfied the notice and consent criteria of section 2799B-2(d) of

the Public Health Service Act with respect to a visit as defined by the Secretary, the Allowed

Amount is based on one of the following in the order listed below as applicable:

▪ The reimbursement rate as determined by a state All Payer Model Agreement.

▪ The reimbursement rate as determined by state law.

▪ The initial payment made by us or the amount subsequently agreed to by the out-of-Network

provider and us.

▪ The amount determined by Independent Dispute Resolution (IDR).

For the purpose of this provision, "certain Network facilities" are limited to a hospital (as defined in

1861(e) of the Social Security Act), a hospital outpatient department, a critical access hospital (as

defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center as described in

section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the Secretary.

IMPORTANT NOTICE: For Ancillary Services, non-Ancillary Services provided without notice and

consent, and non-Ancillary Services for unforeseen or urgent medical needs that arise at the time a

service is provided for which notice and consent has been satisfied, you are not responsible, and

SBN23.CHPSLPDPP.I.2018.SG.ME.rev1

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an out-of-Network Physician may not bill you, for amounts in excess of your applicable Co-

payment, Co-insurance or deductible which is based on the Recognized Amount as defined in the

Certificate.

• For Emergency Health Care Services provided by an out-of-Network provider, the Allowed

Amount is based on one of the following in the order listed below as applicable:

▪ The reimbursement rate as determined by a state All Payer Model Agreement.

▪ The reimbursement rate as determined by state law.

▪ The initial payment made by us or the amount subsequently agreed to by the out-of-Network

provider and us.

▪ The amount determined by Independent Dispute Resolution (IDR).

IMPORTANT NOTICE: You are not responsible, and an out-of-Network provider may not bill you,

for amounts in excess of your applicable Co-payment, Co-insurance or deductible which is based

on the Recognized Amount as defined in the Certificate.

• For Air Ambulance transportation provided by an out-of-Network provider, the Allowed

Amount is based on one of the following in the order listed below as applicable:

▪ The reimbursement rate as determined by a state All Payer Model Agreement.

▪ The reimbursement rate as determined by state law.

▪ The initial payment made by us or the amount subsequently agreed to by the out-of-Network

provider and us.

▪ The amount determined by Independent Dispute Resolution (IDR).

IMPORTANT NOTICE: You are not responsible, and an out-of-Network provider may not bill you,

for amounts in excess of your Co-payment, Co-insurance or deductible which is based on the rates

that would apply if the service was provided by a Network provider which is based on the

Recognized Amount as defined in the Certificate.

• For Emergency ground ambulance transportation provided by an out-of-Network provider,

the Allowed Amount, which includes mileage, is a rate agreed upon by the out-of-Network provider

or, unless a different amount is required by applicable law, determined based upon the median

amount negotiated with Network providers for the same or similar service.

IMPORTANT NOTICE: Out-of-Network providers may bill you for any difference between the

provider's billed charges and the Allowed Amount described here.

When Covered Health Care Services are received from an out-of-Network provider, except as

described above, Allowed Amounts are determined based on either of the following:

• Negotiated rates agreed to by the out-of-Network provider and either us or one of our vendors,

affiliates, or subcontractors.

• If rates have not been negotiated, then one of the following amounts:

▪ Allowed Amounts are determined based on 100% 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, with the exception of the following:

♦ 50% of CMS for the same or similar freestanding laboratory service.

♦ 45% of CMS for the same or similar Durable Medical Equipment from a freestanding

supplier, or CMS competitive bid rates.

♦ 70% of CMS for the same or similar physical therapy service from a freestanding

provider.

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▪ 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:

♦ For services other than Pharmaceutical Products, we use a gap methodology

established by OptumInsight and/or a third-party vendor that uses a relative value

scale or the amount typically accepted by a provider for the same or similar service.

The relative value scale may be based on the difficulty, time, work, risk, location, and

resources of the service. If the relative value scale(s) currently in use become no

longer available, we will use a comparable scale(s). We and OptumInsight are related

companies through common ownership by UnitedHealth Group. Refer to our website

at www.myuhc.com for information regarding the vendor that provides the applicable

gap fill relative value scale information.

♦ 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 for a laboratory service is not published by CMS for the service and gap

methodology does not apply to the service, the rate is based on the average amount

negotiated with similar Network providers for the same or similar service.

♦ When a rate for all other services is not published by CMS for the service and a gap

methodology does not apply to the service, the Allowed Amount is based on 20% of

the provider's billed charge.

We update the CMS published rate data on a regular basis when updated data from CMS becomes

available. These updates are typically put in place within 30 to 90 days after CMS updates its data.

IMPORTANT NOTICE: Out-of-Network providers may bill you for any difference between the

provider's billed charges and the Allowed Amount described here. This includes non-Ancillary

Services when notice and consent is satisfied as described under section 2799B-2(d) of the Public

Health Service Act.

Provider Network

We arrange for health care providers to take part in a Network. Network providers are independent

practitioners. They are not our employees. It is your responsibility to choose 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 the telephone number on your ID card. A

directory of providers is available by contacting us at www.myuhc.com or the telephone number on your

ID card to request a copy. If you receive a Covered Health Care Service from an out-of-Network provider

and were informed incorrectly by us prior to receipt of the Covered Health Care Service that the provider

was a Network provider, either through our database, our provider directory, or in our response to your

request for such information (via telephone, electronic, web-based or internet-based means), you may be

eligible for cost sharing (Co-payment, Co-insurance and applicable deductible) that would be no greater

than if the service had been provided from a Network provider.

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. However, if you are currently receiving

treatment for Covered Health Care Services from a provider whose network status changes from Network

to out-of-Network during such treatment due to termination (non-renewal or expiration) of the provider's

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contract, you may be eligible to request continued care from your current provider under the same terms

and conditions that would have applied prior to termination of the provider's contract for specified

conditions and timeframes. This provision does not apply to provider contract terminations for failure to

meet applicable quality standards or for fraud. If you would like help to find out if you are eligible for

continuity of care Benefits, please call the telephone number on your ID card.

If you are currently undergoing a course of treatment using an out-of-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 to find out if you are eligible for transition of care Benefits,

please call the telephone number on your ID card.

Do not assume that a Network provider's agreement includes all Covered Health Care Services. Some

Network providers contract with us to provide only certain Covered Health Care Services, but not all

Covered Health Care 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 help.

Designated Providers

If you have a medical condition that we believe needs special services, we may direct you to a

Designated Provider chosen by us. If you require certain complex Covered Health Care 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 Care Services from a

Designated Provider, we may reimburse certain travel expenses.

In both cases, Network Benefits will only be paid if your Covered Health Care Services for that condition

are provided by or arranged by the Designated Provider chosen by us.

You or your Network Physician must notify us of special service needs (such as transplants or cancer

treatment) that might warrant referral to a Designated Provider. If you do not notify us in advance, and if

you receive services from an out-of-Network facility (regardless of whether it is a Designated Provider) or

other out-of-Network provider, Network Benefits will not be paid. Out-of-Network Benefits may be

available if the special needs services you receive are Covered Health Care Services for which Benefits

are provided under the Policy.

Health Care Services from Out-of-Network Providers Paid as Network

Benefits

If specific Covered Health Care Services are not available from a Network provider, you may be eligible

for Network Benefits when Covered Health Care Services are received from out-of-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 an out-of-

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 Care 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 do not use the selected Network Physician, Covered Health Care Services will be paid as Out-of-

Network Benefits.

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Real Appeal Rider

UnitedHealthcare Insurance Company

This Rider to the Policy provides Benefits for virtual obesity counseling services for eligible Covered

Persons through Real Appeal. There are no deductibles, Co-payments or Co-insurance you must meet or

pay for when receiving these services.

Real Appeal

Real Appeal provides a virtual lifestyle intervention for weight-related conditions to eligible Covered

Persons 13 years of age or older. Real Appeal is designed to help those at risk from obesity-related

diseases.

This intensive, multi-component behavioral intervention provides 52 weeks of support. This support

includes one-on-one coaching with a live virtual coach and online group participation with supporting

video content. The experience will be personalized for each individual through an introductory online

session.

These Covered Health Care Services will be individualized and may include the following:

• Virtual support and self-help tools: Personal one-on-one coaching, group support sessions,

educational videos, tailored kits, integrated web platform and mobile applications.

• Education and training materials focused on goal setting, problem-solving skills, barriers and

strategies to maintain changes.

• Behavioral change counseling by a specially trained coach for clinical weight loss.

If you would like information regarding these Covered Health Care Services, you may contact us through

www.realappeal.com, https://member.realappeal.com or at the number shown on your ID card.

UnitedHealthcare Insurance Company

Jessica Paik, President

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Virtual Behavioral Health Therapy and Coaching Rider

UnitedHealthcare Insurance Company

This Rider to the Policy provides Benefits for specialized virtual behavioral health care provided by

AbleTo, Inc. for Covered Persons with certain co-occurring behavioral and medical conditions.

Because this Rider 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 in Section 9: Defined Terms.

AbleTo provides behavioral Covered Health Care Services through virtual therapy and coaching services

that are individualized and tailored to your specific health needs. Virtual therapy is provided by licensed

therapists. Coaching services are provided by coaches who are supervised by licensed professionals.

Except for Covered Persons with a high deductible health plan (HDHP) compatible with a Health Savings

Account (HSA), there are no deductibles, Co-payments or Co-insurance you must meet or pay for when

receiving these services.

Except for the initial consultation, Covered Persons with an HSA-compatible high deductible health plan

(HDHP) must meet their Annual Deductible before they are able to receive Benefits for these services.

There are no deductibles, Co-payments or Co-insurance for the initial consultation.

If you would like information regarding these services, you may call us at the telephone number on your

ID card.

UnitedHealthcare Insurance Company

Jessica Paik, President

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UnitedHealthcare Rewards Rider

UnitedHealthcare Insurance Company

This Rider to the Policy is issued to the Group and provides a description of the UnitedHealthcare

Rewards wellness program.

Because this Rider 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 in Section 9: 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 the Subscriber or their

Enrolled Dependent spouse.

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UnitedHealthcare Rewards Program

The Group has implemented a program that rewards you for completing certain wellness criteria, as

described below. You may choose to complete any, or all, of the below wellness criteria to earn a reward.

If you are unable to meet a standard related to a health factor for a reward under the program, then you

might qualify for an opportunity to earn the same reward by different means. You can call us at the

telephone number listed on your ID card, and we will work with you (and, if necessary, with your

Physician) to find another way for you to earn the same reward.

You may receive one or more of the following:

• An activation credit that may be applied towards a device or deposited in your Health Savings

Account (HSA) or distributed in other incentive types as applicable, administered by us.

• A device credit.

• Another type of incentive to help encourage you to participate in the program, administered as

determined by us.

Activity Targets

You may also receive a reward when you meet one or more of the activity targets listed below, based on

the device you choose to track activity.

Activity Marker

Activity Target

Reward

Participation - Fitness

15 minutes of activity as

designated by the program or

5,000 or more steps per day

Active - Fitness

30 minutes or more of activity as

designated by the program or

10,000 or more steps per day

Other Health-Related Actions

and/or Activities

One or more actions and/or

activities defined by us and aimed

at the following:

• Health education;

• Improving health; or

• Maintaining health

You can earn rewards for one or

multiple activity markers.

You may access your actions and/or activity tracking and rewards on the mobile application or

www.myuhc.com.

If you have not achieved any of the above daily activity targets, you may be eligible to earn a reward for

synchronizing or otherwise providing your daily actions and/or activities as defined by the program. This

reward may not be provided if any of the activity targets are met.

The maximum reward will not exceed 30% of the cost of coverage for all programs combined, as

applicable.

Rewards

Rewards listed above, when earned, will be credited to a Health Savings Account (HSA) or distributed in

other reward types as applicable, administered by us.

Device

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A device, which includes an application, approved by us is used to track actions and/or activities towards

earning a reward. If you choose to use a non-compatible device, you may be eligible to earn a reward;

however, the reward may be limited.

UnitedHealthcare Insurance Company

Jessica Paik, President

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Pediatric Dental Services Rider

UnitedHealthcare Insurance Company

How Do You Use This Document?

This Rider to the Policy is issued to the Group and provides Benefits for Covered Dental Services, as

described below, for Covered Persons under the age of 19. Benefits under this Rider will end on the last

day of the month the Covered Person reaches the age of 19.

What Are Defined Terms?

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 5: Defined Terms for Pediatric Dental Services.

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.

UnitedHealthcare Insurance Company

Jessica Paik, President

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Section 1: Accessing Pediatric Dental Services

Network and Out-of-Network Benefits

Network Benefits - these Benefits apply when you choose to obtain Covered Dental Services from a

Network Dental Provider. You generally are required to pay less to the provider than you would pay for

services from an out-of-Network provider. Network Benefits are determined based on the contracted fee

for each Covered Dental Service. In no event, will you be required to pay a Network Dental Provider an

amount for a Covered Dental Service that is greater than the contracted fee.

In order for Covered Dental Services to be paid as Network Benefits, you must obtain all Covered Dental

Services directly from or through a Network Dental Provider.

You must always check the participation status of a provider prior to seeking services. From time to time,

the participation status of a provider may change. You can check the participation status by contacting us

and/or the provider. We can provide help in referring you to Network Dental Provider.

We will make available to you a Directory of Network Dental Providers. You can also call us at the

number stated on your identification (ID) card to determine which providers participate in the Network.

Out-of-Network Benefits - these Benefits apply when you decide to obtain Covered Dental Services

from out-of-Network Dental Providers. You generally are required to pay more to the provider than for

Network Benefits. Out-of-Network Benefits are determined based on the Usual and Customary fee for

similarly situated Network Dental Providers for each Covered Dental Service. The actual charge made by

an out-of-Network Dental Provider for a Covered Dental Service may exceed the Usual and Customary

fee. You may be required to pay an out-of-Network Dental Provider an amount for a Covered Dental

Service that is greater than the Usual and Customary fee. When you obtain Covered Dental Services

from out-of-Network Dental Providers, you must file a claim with us to be reimbursed for Allowed Dental

Amounts.

What Are Covered Dental Services?

You are eligible for Benefits for Covered Dental Services listed in this Rider if such Dental Services are

Necessary and are provided by or under the direction of a Network Dental Provider.

Benefits are available only for Necessary Dental Services. The fact that a Dental Provider has performed

or prescribed a procedure or treatment, or the fact that it may be the only available treatment for a dental

disease, does not mean that the procedure or treatment is a Covered Dental Service under this Rider.

What Is a Pre-Treatment Estimate?

If the charge for a Dental Service is expected to exceed $500 or if a dental exam reveals the need for

fixed bridgework, you may notify us of such treatment before treatment begins and receive a pre-

treatment estimate. If you desire a pre-treatment estimate, you or your Dental Provider should send a

notice to us, via claim form, within 20 calendar days of the exam. If requested, the Dental Provider must

provide us with dental x-rays, study models or other information necessary to evaluate the treatment plan

for purposes of benefit determination.

We will determine if the proposed treatment is a Covered Dental Service and will estimate the amount of

payment. The estimate of Benefits payable will be sent to the Dental Provider and will be subject to all

terms, conditions and provisions of the Policy. Clinical situations that can be effectively treated by a less

costly, clinically acceptable alternative procedure will be given a benefit based on the less costly

procedure.

A pre-treatment estimate of Benefits is not an agreement to pay for expenses. This procedure lets you

know in advance approximately what portion of the expenses will be considered for payment.

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Does Pre-Authorization Apply?

Pre-authorization is required for orthodontic services. Speak to your Dental Provider about obtaining a

pre-authorization before Dental Services are provided. If you do not obtain a pre-authorization, we have a

right to deny your claim for failure to comply with this requirement.

Section 2: Benefits for Pediatric Dental Services

Benefits are provided for the Dental Services stated in this Section when such services are:

A. Necessary.

B. Provided by or under the direction of a Dental Provider.

C. Clinical situations that can be effectively treated by a less costly, dental appropriate alternative

procedure will be given a Benefit based on the least costly procedure.

D. Not excluded as described in Section 3: Pediatric Dental Exclusions of this Rider.

Network Benefits:

Benefits for Allowed Dental Amounts are determined as a percentage of the negotiated contract fee

between us and the provider rather than a percentage of the provider's billed charge. Our negotiated rate

with the provider is ordinarily lower than the provider's billed charge.

A Network provider cannot charge you or us for any service or supply that is not Necessary as

determined by us. If you agree to receive a service or supply that is not Necessary the Network provider

may charge you. However, these charges will not be considered Covered Dental Services and Benefits

will not be payable.

Out-of-Network Benefits:

Benefits for Allowed Dental Amounts from out-of-Network providers are determined as a percentage of

the Usual and Customary fees. You must pay the amount by which the out-of-Network provider's billed

charge exceeds the Allowed Dental Amount.

Annual Deductible

Benefits for pediatric Dental Services provided under this Rider are subject to the Annual Deductible

stated in the Schedule of Benefits, unless otherwise specifically stated.

Out-of-Pocket Limit - any amount you pay in Co-insurance for pediatric Dental Services under this Rider

applies to the Out-of-Pocket Limit stated in the Schedule of Benefits.

Benefits

When Benefit limits apply, the limit stated refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Benefit limits are calculated on a Policy year basis unless otherwise specifically stated.

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Benefit Description

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

Diagnostic Services - Network and Out-of-Network (Subject to payment of the Annual

Deductible.)

Evaluations (Checkup Exams)

Limited to 2 times per 12 months.

Covered as a separate Benefit

only if no other service was done

during the visit other than X-rays.

D0120 - Periodic oral evaluation.

D0140 - Limited oral evaluation -

problem focused.

D9995 - Teledentistry -

synchronous - real time

encounter.

D9996 - Teledentistry -

asynchronous - information

stored and forwarded to dentist

for subsequent review.

D0150 - Comprehensive oral

evaluation - new or established

patient.

D0180 - Comprehensive

periodontal evaluation - new or

established patient.

The following service is not

subject to a frequency limit.

D0160 - Detailed and extensive

oral evaluation - problem focused,

by report.

None

20%

Intraoral Radiographs (X-ray)

Limited to 2 series of films per 12

months.

D0210 - Intraoral - complete

series of radiographic images.

D0709 - Intraoral - complete

series of radiographic images -

None

20%

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Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

image capture only.

The following services are not

subject to a frequency limit.

D0220 - Intraoral - periapical first

radiographic image.

D0230 - Intraoral - periapical -

each additional radiographic

image.

D0240 - Intraoral - occlusal

radiographic image.

D0706 - Intraoral - occlusal

radiographic image - image

capture only.

D0707 - Intraoral - periapical

radiographic image - image

capture only.

None

20%

Any combination of the following

services is limited to 2 series of

films per 12 months.

D0270 - Bitewing - single

radiographic image.

D0272 - Bitewings - two

radiographic images.

D0274 - Bitewings - four

radiographic images.

D0277 - Vertical bitewings - 7 to 8

radiographic images.

D0708 - Intraoral - bitewing

radiographic image - image

capture only.

None

20%

Limited to 1 time per 36 months.

D0330 - Panoramic radiograph

image.

D0701 - Panoramic radiographic

image - image capture only.

D0702 - 2-D Cephalometric

radiographic image - image

None

20%

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Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

capture only.

D0704 - 3-D Photographic image

- image capture only.

The following services are limited

to two images per calendar year.

D0705 - Extra-oral posterior

dental radiographic image -

image capture only.

None

20%

The following services are not

subject to a frequency limit.

D0340 - 2-D Cephalometric

radiographic image - acquisition,

measurement and analysis.

D0350 - 2-D Oral/facial

photographic images obtained

intra-orally or extra-orally.

D0470 - Diagnostic casts.

D0703 - 2-D Oral/facial

photographic image obtained

intra-orally or extra-orally - image

capture only.

None

20%

Preventive Services - Network and Out-of-Network (Subject to payment of the Annual

Deductible.)

Dental Prophylaxis (Cleanings)

The following services are limited

to two times every 12 months.

D1110 - Prophylaxis - adult.

D1120 - Prophylaxis - child.

None

20%

Fluoride Treatments

The following services are limited

to two times every 12 months.

D1206 - Topical application of

fluoride varnish.

D1208 - Topical application of

fluoride - excluding varnish.

None

20%

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Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

Sealants (Protective Coating)

The following services are limited

to once per first or second

permanent molar every 36

months.

D1351 - Sealant - per tooth.

D1352 - Preventive resin

restorations in moderate to high

caries risk patient - permanent

tooth.

None

20%

Space Maintainers (Spacers)

The following services are not

subject to a frequency limit.

D1510 - Space maintainer - fixed,

unilateral - per quadrant.

D1516 - Space maintainer - fixed

- bilateral, maxillary.

D1517 - Space maintainer - fixed

- bilateral, mandibular.

D1520 - Space maintainer -

removable, unilateral - per

quadrant.

D1526 - Space maintainer -

removable - bilateral, maxillary.

D1527 - Space maintainer -

removable - bilateral, mandibular.

D1551 - Re-cement or re-bond

bilateral space maintainer -

maxillary.

D1552 - Re-cement or re-bond

bilateral space maintainer -

mandibular.

D1553 - Re-cement or re-bond

unilateral space maintainer - per

quadrant.

D1556 - Removal of fixed

unilateral space maintainer - per

quadrant.

None

20%

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Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

D1557 - Removal of fixed bilateral

space maintainer - maxillary.

D1558 - Removal of fixed bilateral

space maintainer - mandibular.

D1575 - Distal shoe space

maintainer - fixed - unilateral - per

quadrant.

Minor Restorative Services - Network and Out-of-Network (Subject to payment of the Annual

Deductible.)

Amalgam Restorations (Silver

Fillings)

The following services are not

subject to a frequency limit.

D2140 - Amalgams - one surface,

primary or permanent.

D2150 - Amalgams - two

surfaces, primary or permanent.

D2160 - Amalgams - three

surfaces, primary or permanent.

D2161 - Amalgams - four or more

surfaces, primary or permanent.

20%

40%

Composite Resin Restorations

(Tooth Colored Fillings)

The following services are not

subject to a frequency limit.

D2330 - Resin-based composite -

one surface, anterior.

D2331 - Resin-based composite -

two surfaces, anterior.

D2332 - Resin-based composite -

three surfaces, anterior.

D2335 - Resin-based composite -

four or more surfaces or involving

incisal angle, (anterior).

20%

40%

Crowns/Inlays/Onlays - Network and Out-of-Network (Subject to payment of the Annual

Deductible.)

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Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

The following services are subject

to a limit of one time every 60

months.

D2542 - Onlay - metallic - two

surfaces.

D2543 - Onlay - metallic - three

surfaces.

D2544 - Onlay - metallic - four or

more surfaces.

D2740 - Crown -

porcelain/ceramic.

D2750 - Crown - porcelain fused

to high noble metal.

D2751 - Crown - porcelain fused

to predominately base metal.

D2752 - Crown - porcelain fused

to noble metal.

D2753 - Crown - porcelain fused

to titanium and titanium alloys.

D2780 - Crown - 3/4 cast high

noble metal.

D2781 - Crown - 3/4 cast

predominately base metal.

D2783 - Crown - 3/4

porcelain/ceramic.

D2790 - Crown - full cast high

noble metal.

D2791 - Crown - full cast

predominately base metal.

D2792 - Crown - full cast noble

metal.

D2794 - Crown - titanium and

titanium alloys.

D2930 - Prefabricated stainless

steel crown - primary tooth.

D2931 - Prefabricated stainless

steel crown - permanent tooth.

The following services are not

50%

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Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

subject to a frequency limit.

D2510 - Inlay - metallic - one

surface.

D2520 - Inlay - metallic - two

surfaces.

D2530 - Inlay - metallic - three

surfaces.

D2910 - Re-cement or re-bond

inlay.

D2920 - Re-cement or re-bond

crown.

The following service is not

subject to a frequency limit.

D2940 - Protective restoration.

50%

The following services are limited

to one time per tooth every 60

months.

D2929 - Prefabricated

porcelain/ceramic crown - primary

tooth.

D2950 - Core buildup, including

any pins when required.

50%

The following service is limited to

one time per tooth every 60

months.

D2951 - Pin retention - per tooth,

in addition to restoration.

50%

The following service is not

subject to a frequency limit.

D2954 - Prefabricated post and

core in addition to crown.

50%

The following services are not

subject to a frequency limit.

D2980 - Crown repair

necessitated by restorative

50%

RID23.PDS.NET-OON.I.2018.SG.ME

143

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

material failure.

D2981 - Inlay repair necessitated

by restorative material failure.

D2982 - Onlay repair

necessitated by restorative

material failure.

Endodontics - Network and Out-of-Network (Subject to payment of the Annual Deductible.)

The following service is not

subject to a frequency limit.

D3220 - Therapeutic pulpotomy

(excluding final restoration).

20%

40%

The following service is not

subject to a frequency limit.

D3222 - Partial pulpotomy for

apexogenesis - permanent tooth

with incomplete root

development.

20%

40%

The following services are not

subject to a frequency limit.

D3230 - Pulpal therapy

(resorbable filling) - anterior

primary tooth (excluding final

restoration).

D3240 - Pulpal therapy

(resorbable filling) - posterior,

primary tooth (excluding final

restoration).

20%

40%

The following services are not

subject to a frequency limit.

D3310 - Endodontic therapy

anterior tooth (excluding final

restoration).

D3320 - Endodontic therapy,

premolar tooth (excluding final

restoration).

D3330 - Endodontic therapy,

molar tooth (excluding final

20%

40%

RID23.PDS.NET-OON.I.2018.SG.ME

144

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

restoration).

D3346 - Retreatment of previous

root canal therapy - anterior.

D3347 - Retreatment of previous

root canal therapy - bicuspid.

D3348 - Retreatment of previous

root canal therapy - molar.

The following services are not

subject to a frequency limit.

D3351 -

Apexification/recalcification -

initial visit.

D3352 -

Apexification/recalcification/pulpal

regeneration - interim medication

replacement.

D3353 -

Apexification/recalcification - final

visit.

20%

40%

The following services are not

subject to a frequency limit.

D3410 - Apicoectomy - anterior.

D3421 - Apicoectomy - premolar

(first root).

D3425 - Apicoectomy - molar

(first root).

D3426 - Apicoectomy (each

additional root).

D3450 - Root amputation - per

root.

D3471 - Surgical repair of root

resorption - anterior.

D3472 - Surgical repair of root

resorption - premolar.

D3473 - Surgical repair of root

resorption - molar.

D3501 - Surgical exposure of root

20%

40%

RID23.PDS.NET-OON.I.2018.SG.ME

145

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

surface without apicoectomy or

repair of root resorption - anterior.

D3502 - Surgical exposure of root

surface without apicoectomy or

repair of root resorption -

premolar.

D3503 - Surgical exposure of root

surface without apicoectomy or

repair of root resorption - molar.

The following services are not

subject to a frequency limit.

D3911 - Intraorifice barrier.

D3920 - Hemisection (including

any root removal), not including

root canal therapy.

20%

40%

Periodontics - Network and Out-of-Network (Subject to payment of the Annual Deductible.)

The following services are limited

to a frequency of one every 36

months.

D4210 - Gingivectomy or

gingivoplasty - four or more

contiguous teeth or tooth

bounded spaces per quadrant.

D4211 - Gingivectomy or

gingivoplasty - one to three

contiguous teeth or tooth

bounded spaces per quadrant.

20%

40%

The following services are limited

to one every 36 months.

D4240 - Gingival flap procedure,

including root planing - four or

more contiguous teeth or tooth

bounded spaces per quadrant.

D4241 - Gingival flap procedure,

including root planing - one to

three contiguous teeth or tooth

bounded spaces per quadrant.

D4249 - Clinical crown

20%

40%

RID23.PDS.NET-OON.I.2018.SG.ME

146

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

lengthening - hard tissue.

The following services are limited

to one every 36 months.

D4260 - Osseous surgery

(including flap entry and closure) -

four or more contiguous teeth or

tooth bounded spaces per

quadrant.

D4261 - Osseous surgery

(including flap entry and closure),

one to three contiguous teeth or

bounded teeth spaces per

quadrant.

D4263 - Bone replacement graft -

retained natural tooth - first site in

quadrant.

20%

40%

The following service is not

subject to a frequency limit.

D4270 - Pedicle soft tissue graft

procedure.

20%

40%

The following services are not

subject to a frequency limit.

D4273 - Autogenous connective

tissue graft procedure, per first

tooth implant or edentulous tooth

position in graft.

D4275 - Non-autogenous

connective tissue graft first tooth

implant.

D4277 - Free soft tissue graft

procedure - first tooth.

D4278 - Free soft tissue graft

procedure - each additional

contiguous tooth.

D4322 - Splint - intra-coronal;

natural teeth or prosthetic crowns.

D4323 - Splint - extra-coronal;

natural teeth or prosthetic crowns.

20%

40%

RID23.PDS.NET-OON.I.2018.SG.ME

147

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

The following services are limited

to one time per quadrant every 24

months.

D4341 - Periodontal scaling and

root planing - four or more teeth

per quadrant.

D4342 - Periodontal scaling and

root planing - one to three teeth

per quadrant.

D4346 - Scaling in presence of

generalized moderate or severe

gingival inflammation - full mouth,

after oral evaluation.

20%

40%

The following service is limited to

a frequency to one per lifetime.

D4355 - Full mouth debridement

to enable comprehensive oral

evaluation and diagnosis on

subsequent visit.

20%

40%

The following service is limited to

four times every 12 months in

combination with prophylaxis.

D4910 - Periodontal

maintenance.

20%

40%

Removable Dentures - Network and Out-of-Network (Subject to payment of the Annual

Deductible.)

The following services are limited

to a frequency of one every 60

months.

D5110 - Complete denture -

maxillary.

D5120 - Complete denture -

mandibular.

D5130 - Immediate denture -

maxillary.

D5140 - Immediate denture -

mandibular.

50%

RID23.PDS.NET-OON.I.2018.SG.ME

148

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

D5211 - Maxillary partial denture -

resin base (including

retentive/clasping materials,

rests, and teeth).

D5212 - Mandibular partial

denture - resin base (including

retentive/clasping materials,

rests, and teeth).

D5213 - Maxillary partial denture -

cast metal framework with resin

denture bases (including

retentive/clasping materials, rests

and teeth).

D5214 - Mandibular partial

denture - cast metal framework

with resin denture bases

(including retentive/clasping

materials, rests and teeth).

D5221 - Immediate maxillary

partial denture - resin base

(including retentive/clasping

materials, rests and teeth).

D5222 - Immediate mandibular

partial denture - resin base

(including retentive/clasping

materials, rests and teeth).

D5223 - Immediate maxillary

partial denture - cast metal

framework with resin denture

bases (including

retentive/clasping materials, rests

and teeth).

D5224 - Immediate mandibular

partial denture - cast metal

framework with resin denture

bases (including

retentive/clasping materials, rests

and teeth).

D5227 - Immediate maxillary

partial denture - flexible base

(including any clasps, rests, and

teeth).

RID23.PDS.NET-OON.I.2018.SG.ME

149

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

D5228 - Immediate mandibular

partial denture - flexible base

(including any clasps, rests, and

teeth).

D5282 - Removable unilateral

partial denture - one piece cast

metal (including retentive/clasping

materials, rests, and teeth),

maxillary.

D5283 - Removable unilateral

partial denture - one piece cast

metal (including retentive/clasping

materials, rests, and teeth),

mandibular.

D5284 - Removable unilateral

partial denture - one piece flexible

base (including retentive/clasping

materials, rests, and teeth) - per

quadrant.

D5286 - Removable unilateral

partial denture - one piece resin

(including retentive/clasping

materials, rests, and teeth) - per

quadrant.

The following services are not

subject to a frequency limit.

D5410 - Adjust complete denture

- maxillary.

D5411 - Adjust complete denture

- mandibular.

D5421 - Adjust partial denture -

maxillary.

D5422 - Adjust partial denture -

mandibular.

D5511 - Repair broken complete

denture base - mandibular.

D5512 - Repair broken complete

denture base - maxillary.

D5520 - Replace missing or

broken teeth - complete denture

50%

RID23.PDS.NET-OON.I.2018.SG.ME

150

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

(each tooth).

D5611 - Repair resin partial

denture base - mandibular.

D5612 - Repair resin partial

denture base - maxillary.

D5621 - Repair cast partial

framework - mandibular.

D5622 - Repair cast partial

framework - maxillary.

D5630 - Repair or replace broken

retentive/clasping materials - per

tooth.

D5640 - Replace broken teeth -

per tooth.

D5650 - Add tooth to existing

partial denture.

D5660 - Add clasp to existing

partial denture.

The following services are limited

to rebasing performed more than

6 months after the initial insertion

with a frequency limitation of one

time per 12 months.

D5710 - Rebase complete

maxillary denture.

D5711 - Rebase complete

mandibular denture.

D5720 - Rebase maxillary partial

denture.

D5721 - Rebase mandibular

partial denture.

D5725 - Rebase hybrid

prosthesis.

D5730 - Reline complete

maxillary denture (direct).

D5731 - Reline complete

mandibular denture (direct).

D5740 - Reline maxillary partial

50%

RID23.PDS.NET-OON.I.2018.SG.ME

151

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

denture (direct).

D5741 - Reline mandibular partial

denture (direct).

D5750 - Reline complete

maxillary denture (indirect).

D5751 - Reline complete

mandibular denture (indirect).

D5760 - Reline maxillary partial

denture (indirect).

D5761 - Reline mandibular partial

denture (indirect).

D5876 - Add metal substructure

to acrylic full denture (per arch).

The following services are not

subject to a frequency limit.

D5765 - Soft liner for complete or

partial removable denture -

indirect.

D5850 - Tissue conditioning

(maxillary).

D5851 - Tissue conditioning

(mandibular).

50%

Bridges (Fixed partial dentures (FPD)) - Network and Out-of-Network (Subject to payment of the

Annual Deductible.)

The following services are not

subject to a frequency limit.

D6210 - Pontic - cast high noble

metal.

D6211 - Pontic - cast

predominately base metal.

D6212 - Pontic - cast noble metal.

D6214 - Pontic - titanium and

titanium alloys.

D6240 - Pontic - porcelain fused

to high noble metal.

D6241 - Pontic - porcelain fused

50%

RID23.PDS.NET-OON.I.2018.SG.ME

152

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

to predominately base metal.

D6242 - Pontic - porcelain fused

to noble metal.

D6243 - Pontic - porcelain fused

to titanium and titanium alloys.

D6245 - Pontic -

porcelain/ceramic.

The following services are not

subject to a frequency limit.

D6545 - Retainer - cast metal for

resin bonded fixed prosthesis.

D6548 - Retainer -

porcelain/ceramic for resin

bonded fixed prosthesis.

50%

The following services are limited

to one time every 60 months.

D6740 - Retainer crown -

porcelain/ceramic.

D6750 - Retainer crown -

porcelain fused to high noble

metal.

D6751 - Retainer crown -

porcelain fused to predominately

base metal.

D6752 - Retainer crown -

porcelain fused to noble metal.

D6753 - Retainer crown -

porcelain fused to titanium and

titanium alloys.

D6780 - Retainer crown - 3/4 cast

high noble metal.

D6781 - Retainer crown - 3/4 cast

predominately base metal.

D6782 - Retainer crown - 3/4 cast

noble metal.

D6783 - Retainer crown - 3/4

porcelain/ceramic.

50%

RID23.PDS.NET-OON.I.2018.SG.ME

153

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

D6784 - Retainer crown - 3/4

titanium and titanium alloys.

D6790 - Retainer crown - full cast

high noble metal.

D6791 - Retainer crown - full cast

predominately base metal.

D6792 - Retainer crown - full cast

noble metal.

The following service is not

subject to a frequency limit.

D6930 - Re-cement or re-bond

FPD.

50%

The following services are not

subject to a frequency limit.

D6980 - FPD repair necessitated

by restorative material failure.

50%

Oral Surgery - Network and Out-of-Network (Subject to payment of the Annual Deductible.)

The following service is not

subject to a frequency limit.

D7140 - Extraction, erupted tooth

or exposed root.

20%

40%

The following services are not

subject to a frequency limit.

D7210 - Surgical removal of

erupted tooth requiring removal of

bone, sectioning of tooth, and

including elevation of

mucoperiosteal flap, if indicated.

D7220 - Removal of impacted

tooth - soft tissue.

D7230 - Removal of impacted

tooth - partially bony.

D7240 - Removal of impacted

tooth - completely bony.

D7241 - Removal of impacted

tooth - completely bony with

20%

40%

RID23.PDS.NET-OON.I.2018.SG.ME

154

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

unusual surgical complications.

D7250 - Surgical removal or

residual tooth roots.

D7251 - Coronectomy -

intentional partial tooth removal.

The following service is not

subject to a frequency limit.

D7270 - Tooth reimplantation

and/or stabilization of accidentally

evulsed or displaced tooth.

20%

40%

The following service is not

subject to a frequency limit.

D7280 - Surgical access

exposure of an unerupted tooth.

20%

40%

The following services are not

subject to a frequency limit.

D7310 - Alveoloplasty in

conjunction with extractions - four

or more teeth or tooth spaces, per

quadrant.

D7311 - Alveoloplasty in

conjunction with extraction - one

to three teeth or tooth spaces -

per quadrant.

D7320 - Alveoloplasty not in

conjunction with extractions - four

or more teeth or tooth spaces, per

quadrant.

D7321 - Alveoloplasty not in

conjunction with extractions - one

to three teeth or tooth space - per

quadrant.

20%

40%

The following service is not

subject to a frequency limit.

D7471 - removal of lateral

exostosis (maxilla or mandible).

20%

40%

RID23.PDS.NET-OON.I.2018.SG.ME

155

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

The following services are not

subject to a frequency limit.

D7510 - Incision and drainage of

abscess, intraoral soft tissue.

D7910 - Suture of recent small

wounds up to 5 cm.

D7953 - Bone replacement graft

for ridge preservation - per site.

D7961 - Buccal/labial frenectomy

(frenulectomy).

D7962 - Lingual frenectomy

(frenulectomy).

D7971 - Excision of pericoronal

gingiva.

20%

40%

Adjunctive Services - Network and Out-of-Network (Subject to payment of the Annual

Deductible.)

The following service is not

subject to a frequency limit;

however, it is covered as a

separate Benefit only if no other

services (other than the exam

and radiographs) were done on

the same tooth during the visit.

D9110 - Palliative (Emergency)

treatment of dental pain - minor

procedure.

20%

40%

Covered only when clinically

Necessary.

D9222 - Deep sedation/general

anesthesia - first 15 minutes.

D9223 - Deep sedation/general

anesthesia - each 15 minute

increment.

D9239 - Intravenous moderate

(conscious) sedation/anesthesia -

first 15 minutes.

D9610 - Therapeutic parenteral

20%

40%

RID23.PDS.NET-OON.I.2018.SG.ME

156

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

drug single administration.

Covered only when clinically

Necessary.

D9310 - Consultation (diagnostic

service provided by a dentist or

Physician other than the

practitioner providing treatment).

20%

40%

The following is limited to one

guard every 12 months.

D9944 - Occlusal guard - hard

appliance, full arch.

D9945 - Occlusal guard - soft

appliance, full arch.

D9946 - Occlusal guard - hard

appliance, partial arch.

20%

40%

The following services are not

subject to a frequency limit.

D9930 - Treatment of

complications (post-surgical) -

unusual circumstances, by report.

20%

40%

Implant Procedures - Network and Out-of-Network (Subject to payment of the Annual Deductible.)

The following services are limited

to one time every 60 months.

D6010 - Surgical placement of

implant body: endosteal implant.

D6012 - Surgical placement of

interim implant body.

D6040 - Surgical placement of

eposteal implant.

D6050 - Surgical placement:

transosteal implant.

D6055 - Connecting bar - implant

supported or abutment supported.

D6056 - Prefabricated abutment -

includes modification and

50%

RID23.PDS.NET-OON.I.2018.SG.ME

157

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

placement.

D6057 - Custom fabricated

abutment - includes placement.

D6058 - Abutment supported

porcelain/ceramic crown.

D6059 - Abutment supported

porcelain fused to metal crown

(high noble metal).

D6060 - Abutment supported

porcelain fused to metal crown

(predominately base metal).

D6061 - Abutment supported

porcelain fused to metal crown

(noble metal).

D6062 - Abutment supported cast

metal crown (high noble metal).

D6063 - Abutment supported cast

metal crown (predominately base

metal).

D6064 - Abutment supported cast

metal crown (noble metal).

D6065 - Implant supported

porcelain/ceramic crown.

D6066 - Implant supported crown

- porcelain fused to high noble

alloys.

D6067 - Implant supported crown

- high noble alloys.

D6068 - Abutment supported

retainer for porcelain/ceramic

FPD.

D6069 - Abutment supported

retainer for porcelain fused to

metal FPD (high noble metal).

D6070 - Abutment supported

retainer for porcelain fused to

metal FPD (predominately base

metal).

D6071 - Abutment supported

RID23.PDS.NET-OON.I.2018.SG.ME

158

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

retainer for porcelain fused to

metal FPD (noble metal).

D6072 - Abutment supported

retainer for cast metal FPD (high

noble metal).

D6073 - Abutment supported

retainer for cast metal FPD

(predominately base metal).

D6074 - Abutment supported

retainer for cast metal FPD (noble

metal).

D6075 - Implant supported

retainer for ceramic FPD.

D6076 - Implant supported

retainer for FPD - porcelain fused

to high noble alloys.

D6077 - Implant supported

retainer for metal FPD - high

noble alloys.

D6080 - Implant maintenance

procedure.

D6081 - Scaling and debridement

in the presence of inflammation or

mucositis of a single implant,

including cleaning of the implant

surfaces, without flap entry and

closure.

D6082 - Implant supported crown

- porcelain fused to predominantly

base alloys.

D6083 - Implant supported crown

- porcelain fused to noble alloys.

D6084 - Implant supported crown

- porcelain fused to titanium and

titanium alloys.

D6086 - Implant supported crown

- predominantly base alloys.

D6087 - Implant supported crown

- noble alloys.

D6088 - Implant supported crown

RID23.PDS.NET-OON.I.2018.SG.ME

159

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

- titanium and titanium alloys.

D6090 - Repair implant supported

prosthesis, by report.

D6091 - Replacement of

replaceable part of semi-precision

or precision attachment of

implant/abutment supported

prosthesis, per attachment.

D6095 - Repair implant abutment,

by report.

D6096 - Remove broken implant

retaining screw.

D6097 - Abutment supported

crown - porcelain fused to

titanium and titanium alloys.

D6098 - Implant supported

retainer - porcelain fused to

predominantly base alloys.

D6099 - Implant supported

retainer for FPD - porcelain fused

to noble alloys.

D6100 - Surgical removal of

implant body.

D6101 - Debridement peri-implant

defect.

D6102 - Debridement and

osseous contouring of a peri-

implant defect.

D6103 - Bone graft for repair peri-

implant defect.

D6104 - Bone graft at time of

implant replacement.

D6118 - Implant/abutment

supported interim fixed denture

for edentulous arch - mandibular.

D6119 - Implant/abutment

supported interim fixed denture

for edentulous arch - maxillary.

D6120 - Implant supported

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Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

retainer - porcelain fused to

titanium and titanium alloys.

D6121 - Implant supported

retainer for metal FPD -

predominantly base alloys.

D6122 - Implant supported

retainer for metal FPD - noble

alloys.

D6123 - Implant supported

retainer for metal FPD - titanium

and titanium alloys.

D6190 - Radiographic/surgical

implant index, by report.

D6191 - Semi-precision abutment

- placement.

D6192 - Semi-precision

attachment - placement.

D6195 - Abutment supported

retainer - porcelain fused to

titanium and titanium alloys.

Medically Necessary Orthodontics - Network and Out-of-Network (Subject to payment of the

Annual Deductible.)

Benefits for comprehensive orthodontic treatment are approved by us, only in those instances that are

related to an identifiable syndrome such as cleft lip and or palate, Crouzon's Syndrome, Treacher-Collins

Syndrome, Pierre-Robin Syndrome, hemi-facial atrophy, hemi-facial hypertrophy; or other severe

craniofacial deformities which result in a physically handicapping malocclusion as determined by our

dental consultants. Benefits are not available for comprehensive orthodontic treatment for crowded

dentitions (crooked teeth), excessive spacing between teeth, temporomandibular joint (TMJ) conditions

and/or having horizontal/vertical (overjet/overbite) discrepancies.

All orthodontic treatment must be prior authorized.

Benefits will be paid in equal monthly installments over the course of the entire orthodontic treatment

plan, starting on the date that the orthodontic bands or appliances are first placed, or on the date a one-

step orthodontic procedure is performed.

Services or supplies furnished by a Dental Provider in order to diagnose or correct misalignment of the

teeth or the bite. Benefits are available only when the service or supply is determined to be medically

Necessary.

The following services are not

subject to a frequency limitation

as long as benefits have been

50%

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Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

prior authorized.

D8010 - Limited orthodontic

treatment of the primary dentition.

D8020 - Limited orthodontic

treatment of the transitional

dentition.

D8030 - Limited orthodontic

treatment of the adolescent

dentition.

D8070 - Comprehensive

orthodontic treatment of the

transitional dentition.

D8080 - Comprehensive

orthodontic treatment of the

adolescent dentition.

D8210 - Removable appliance

therapy.

D8220 - Fixed appliance therapy.

D8660 - Pre-orthodontic

treatment visit.

D8670 - Periodic orthodontic

treatment visit.

D8680 - Orthodontic retention.

D8695 - Removal of fixed

orthodontic appliances for

reasons other than completion of

treatment.

D8696 - Repair of orthodontic

appliance - maxillary.

D8697 - Repair of orthodontic

appliance - mandibular.

D8698 - Re-cement or re-bond

fixed retainer - maxillary.

D8699 - Re-cement or re-bond

fixed retainer - mandibular.

D8701 - Repair of fixed retainer,

includes reattachment - maxillary.

D8702 - Repair of fixed retainer,

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Amounts which you are required to pay as shown below in the Schedule of Benefits are based on

Allowed Dental Amounts.

What Are the Procedure Codes,

Benefit Description and

Frequency Limitations?

Network Benefits - The Amount

You Pay Which May Include a

Co-insurance or Co-Payment.

Out-of-Network Benefits - The

Amount You Pay Which is

Shown as a Percentage of

Allowed Dental Amounts.

includes reattachment -

mandibular.

Section 3: Pediatric Dental Exclusions

Except as may be specifically provided in this Rider under Section 2: Benefits for Pediatric Dental

Services, Benefits are not provided under this Rider for the following:

1. Any Dental Service or Procedure not listed as a Covered Dental Service in this Rider in Section 2:

Benefits for Pediatric Dental Services.

2. Dental Services that are not Necessary.

3. Hospitalization or other facility charges.

4. Any Dental Procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are

those procedures that improve physical appearance.)

5. Reconstructive surgery, regardless of whether or not the surgery is related to a dental disease,

Injury, or Congenital Anomaly, when the primary purpose is to improve physiological functioning of

the involved part of the body.

6. Any Dental Procedure not directly related with dental disease.

7. Any Dental Procedure not performed in a dental setting.

8. Procedures that are considered to be Experimental or Investigational or Unproven Services. This

includes pharmacological regimens not accepted by the American Dental Association (ADA)

Council on Dental Therapeutics. The fact that an Experimental, or Investigational 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.

9. Drugs/medications, received with or without a prescription, unless they are dispensed and used in

the dental office during the patient visit.

10. Setting of facial bony fractures and any treatment related with the dislocation of facial skeletal hard

tissue.

11. Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except

excisional removal. Treatment of malignant neoplasms or Congenital Anomalies of hard or soft

tissue, including excision.

12. Replacement of complete dentures, fixed and removable partial dentures or crowns and implants,

implant crowns and prosthesis if damage or breakage was directly related to provider error. This

type of replacement is the responsibility of the Dental Provider. If replacement is Necessary

because of patient non-compliance, the patient is liable for the cost of replacement.

13. Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and

lower jaw bone surgery (including that related to the temporomandibular joint). Orthognathic

surgery, jaw alignment, and treatment for the temporomandibular joint.

14. Charges for not keeping a scheduled appointment without giving the dental office 24 hours notice.

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15. Expenses for Dental Procedures begun prior to the Covered Person becoming enrolled for

coverage provided through this Rider to the Policy.

16. Dental Services otherwise covered under the Policy, but provided after the date individual coverage

under the Policy ends, including Dental Services for dental conditions arising prior to the date

individual coverage under the Policy ends.

17. Services rendered by a provider with the same legal residence as you or who is a member of your

family, including spouse, brother, sister, parent or child.

18. Foreign Services are not covered unless required as an Emergency.

19. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or

reconstruction.

20. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion

(VDO).

21. Billing for incision and drainage if the involved abscessed tooth is removed on the same date of

service.

22. Placement of fixed partial dentures solely for the purpose of achieving periodontal stability.

23. Acupuncture; acupressure and other forms of alternative treatment, whether or not used as

anesthesia.

24. Orthodontic coverage does not include the installation of a space maintainer, any treatment related

to treatment of the temporomandibular joint, any surgical procedure to correct a malocclusion,

replacement of lost or broken retainers and/or habit appliances, and any fixed or removable

interceptive orthodontic appliances previously submitted for payment under the plan.

Section 4: Claims for Pediatric Dental Services

When receiving Dental Services from an out-of-Network provider, you will be required to pay all billed

charges directly to your Dental Provider. You may then seek reimbursement from us. Information about

claim timelines and responsibilities in the Certificate in Section 5: How to File a Claim applies to Covered

Dental Services provided under this Rider, except that when you submit your claim, you must provide us

with all of the information shown below.

Reimbursement for Dental Services

You are responsible for sending a request for reimbursement to our office, on a form provided by or

satisfactory to us.

Claim Forms. It is not necessary to include a claim form with the proof of loss. However, the proof must

include all of the following information:

• Covered Person's name and address.

• Covered Person's identification number.

• The name and address of the provider of the service(s).

• A diagnosis from the Dental Provider including a complete dental chart showing extractions, fillings

or other dental services provided before the charge was incurred for the claim.

• Radiographs, lab or hospital reports.

• Casts, molds or study models.

• Itemized bill which includes the CPT or ADA codes or description of each charge.

• The date the dental disease began.

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• A statement indicating that you are or you are not enrolled for coverage under any other health or

dental insurance plan or program. If you are enrolled for other coverage you must include the name

of the other carrier(s).

If you would like to use a claim form, call us at the telephone number stated on your ID card and a claim

form will be sent to you. If you do not receive the claim form within 15 calendar days of your request, send

in the proof of loss with the information stated above.

Section 5: Defined Terms for Pediatric Dental Services

The following definitions are in addition to those listed in Section 9: Defined Terms of the Certificate:

Allowed Dental Amounts - Allowed Dental Amounts for Covered Dental Services, incurred while the

Policy is in effect, are determined as stated below:

• For Network Benefits, when Covered Dental Services are received from Network Dental Providers,

Allowed Dental Amounts are our contracted fee(s) for Covered Dental Services with that provider.

• For Out-of-Network Benefits, when Covered Dental Services are received from Out-of-Network

Dental Providers, Allowed Dental Amounts are the Usual and Customary fees, as defined below.

Covered Dental Service - a Dental Service or Dental Procedure for which Benefits are provided under

this Rider.

Dental Provider - any dentist or dental practitioner who is duly licensed and qualified under the law of

jurisdiction in which treatment is received to provide Dental Services, perform dental surgery or provide

anesthetics for dental surgery.

Dental Service or Dental Procedures - dental care or treatment provided by a Dental Provider to a

Covered Person while the Policy is in effect, provided such care or treatment is recognized by us as a

generally accepted form of care or treatment according to prevailing standards of dental practice.

Necessary - Dental Services and supplies under this Rider which are determined by us through case-by-

case assessments of care based on accepted dental practices to be appropriate and are all of the

following:

• Necessary to meet the basic dental needs of the Covered Person.

• Provided in the most cost-efficient manner and type of setting appropriate for the delivery of the

Dental Service.

• Consistent in type, frequency and duration of treatment with scientifically based guidelines of

national clinical, research, or health care coverage organizations or governmental agencies that

are accepted by us.

• Consistent with the diagnosis of the condition.

• Required for reasons other than the convenience of the Covered Person or his or her Dental

Provider.

• Demonstrated through prevailing peer-reviewed dental literature to be either:

▪ Safe and effective for treating or diagnosing the condition or sickness for which their use is

proposed; or

▪ Safe with promising efficacy

♦ For treating a life threatening dental disease or condition.

♦ Provided in a clinically controlled research setting.

♦ Using a specific research protocol that meets standards equivalent to those defined

by the National Institutes of Health.

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(For the purpose of this definition, the term life threatening is used to describe dental diseases or

sicknesses or conditions, which are more likely than not to cause death within one year of the date of the

request for treatment.)

The fact that a Dental Provider has performed or prescribed a procedure or treatment or the fact that it

may be the only treatment for a particular dental disease does not mean that it is a Necessary Covered

Dental Service as defined in this Rider. The definition of Necessary used in this Rider relates only to

Benefits under this Rider and differs from the way in which a Dental Provider engaged in the practice of

dentistry may define necessary.

Usual and Customary - Usual and Customary fees are calculated by us based on available data

resources of competitive fees in that geographic area.

Usual and Customary fees must not exceed the fees that the provider would charge any similarly situated

payor for the same services.

Usual and Customary fees are determined solely in accordance with our reimbursement policy guidelines.

Our reimbursement policy guidelines are developed by us, 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 (publication of the

American Dental Association).

• As reported by generally recognized professionals or publications.

• As used for Medicare.

• As determined by medical or dental staff and outside medical or dental consultants.

• Pursuant to other appropriate source or determination that we accept.

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Pediatric Vision Care Services Rider

UnitedHealthcare Insurance Company

How Do You Use This Document?

This Rider to the Policy is issued to the Group and provides Benefits for Vision Care Services, as

described below, for Covered Persons under the age of 19. Benefits under this Rider will end on the last

day of the month the Covered Person reaches the age of 19.

What Are Defined Terms?

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 4: Defined Terms for Pediatric Vision Care Services.

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.

UnitedHealthcare Insurance Company

Jessica Paik, President

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Section 1: Benefits for Pediatric Vision Care Services

Benefits are available for pediatric Vision Care Services from a UnitedHealthcare Vision Network or out-

of-Network Vision Care Provider. To find a UnitedHealthcare Vision Network Vision Care Provider, you

may call the provider locator service at 1-800-839-3242. You may also access a listing of

UnitedHealthcare Vision Network Vision Care Providers on the Internet at www.myuhcvision.com.

When you obtain Vision Care Services from an out-of-Network Vision Care Provider, you will be required

to pay all billed charges at the time of service. You may then seek payment from us as described in the

Certificate in Section 5: How to File a Claim and in this Rider under Section 3: Claims for Pediatric Vision

Care Services. Reimbursement will be limited to the amounts stated below.

When obtaining these Vision Care Services from a UnitedHealthcare Vision Network Vision Care

Provider, you will be required to pay any Co-payments at the time of service.

Network Benefits:

Benefits for Vision Care Services are determined based on the negotiated contract fee between us and

the Vision Care Provider. Our negotiated rate with the Vision Care Provider is ordinarily lower than the

Vision Care Provider's billed charge.

Out-of-Network Benefits:

Benefits for Vision Care Services from out-of-Network providers are determined as a percentage of the

provider's billed charge.

Out-of-Pocket Limit - any amount you pay in Co-insurance for Vision Care Services under this Rider

applies to the Out-of-Pocket Limit stated in the Schedule of Benefits. Any amount you pay in Co-

payments for Vision Care Services under this Rider applies to the Out-of-Pocket Limit stated in the

Schedule of Benefits.

Annual Deductible

Benefits for pediatric Vision Care Services provided under this Rider are subject to any Annual Deductible

stated in the Schedule of Benefits unless otherwise specifically stated. Any amount you pay in Co-

payments for Vision Care Services under this Rider does not apply to the Annual Deductible stated in the

Schedule of Benefits

What Are the Benefit Descriptions?

Benefits

When Benefit limits apply, the limit stated refers to any combination of Network Benefits and Out-of-

Network Benefits unless otherwise specifically stated.

Benefit limits are calculated on a year basis unless otherwise specifically stated.

Frequency of Service Limits

Benefits are provided for the Vision Care Services described below, subject to Frequency of Service limits

and Co-payments and Co-insurance stated under each Vision Care Service in the Schedule of Benefits

below.

Routine Vision Exam

A routine vision exam of the eyes and according to the standards of care in your area, including:

• A patient history that includes reasons for exam, patient medical/eye history, and current

medications.

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• Visual acuity with each eye and both eyes, far and near, with and without glasses or contact lenses

(for example, 20/20 and 20/40).

• Cover test at 20 feet and 16 inches (checks how the eyes work together as a team).

• Ocular motility (how the eyes move) near point of convergence (how well eyes move together for

near vision tasks, such as reading), and depth perception (3D vision).

• Pupil reaction to light and focusing.

• Exam of the eye lids, lashes, and outside of the eye.

• Retinoscopy (when needed) - helps to determine the starting point of the refraction which

determines the lens power of the glasses.

• Phorometry/Binocular testing - far and near (how well eyes work as a team).

• Tests of accommodation - how well you see up close (for example, reading).

• Tonometry, when indicated - test pressure in eye (glaucoma check).

• Ophthalmoscopic exam of the inside of the eye.

• Visual field testing.

• Color vision testing.

• Diagnosis/prognosis.

• Specific recommendations.

Post exam procedures will be performed only when materials are required.

Or, in lieu of a complete exam, Retinoscopy (when applicable) - objective refraction to determine lens

power of corrective lenses and subjective refraction to determine lens power of corrective lenses.

Eyeglass Lenses

Lenses that are placed in eyeglass frames and worn on the face to correct visual acuity limitations.

You are eligible to choose only one of either eyeglasses (Eyeglass Lenses and/or Eyeglass Frames) or

Contact Lenses. If you choose more than one of these Vision Care Services, we will pay Benefits for only

one Vision Care Service.

If you purchase Eyeglass Lenses and Eyeglass Frames at the same time from the same

UnitedHealthcare Vision Network Vision Care Provider, only one Co-payment will apply to those Eyeglass

Lenses and Eyeglass Frames together.

Eyeglass Frames

A structure that contains eyeglass lenses, holding the lenses in front of the eyes and supported by the

bridge of the nose.

You are eligible to choose only one of either eyeglasses (Eyeglass Lenses and/or Eyeglass Frames) or

Contact Lenses. If you choose more than one of these Vision Care Services, we will pay Benefits for only

one Vision Care Service.

If you purchase Eyeglass Lenses and Eyeglass Frames at the same time from the same

UnitedHealthcare Vision Network Vision Care Provider, only one Co-payment will apply to those Eyeglass

Lenses and Eyeglass Frames together.

Contact Lenses

Lenses worn on the surface of the eye to correct visual acuity limitations.

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Benefits include the fitting/evaluation fees, contact lenses, and follow-up care.

You are eligible to choose only one of either eyeglasses (Eyeglass Lenses and/or Eyeglass Frames) or

Contact Lenses. If you choose more than one of these Vision Care Services, we will pay Benefits for only

one Vision Care Service.

Necessary Contact Lenses

Benefits are available when a Vision Care Provider has determined a need for and has prescribed the

contact lens. Such determination will be made by the Vision Care Provider and not by us.

Contact lenses are necessary if you have any of the following:

• Keratoconus.

• Anisometropia.

• Irregular corneal/astigmatism.

• Aphakia.

• Facial deformity.

• Corneal deformity.

• Pathological myopia.

• Aniseikonia.

• Aniridia.

• Post-traumatic disorders.

Low Vision

Benefits are available to Covered Persons who have severe visual problems that cannot be corrected

with regular lenses and only when a Vision Care Provider has determined a need for and has prescribed

the service. Such determination will be made by the Vision Care Provider and not by us.

Benefits include:

• Low vision testing: Complete low vision analysis and diagnosis which includes:

▪ A comprehensive exam of visual functions.

▪ The prescription of corrective eyewear or vision aids where indicated.

▪ Any related follow-up care.

• Low vision therapy: Subsequent low vision therapy if prescribed.

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Schedule of Benefits

Vision Care Service

What Is the Frequency

of Service?

Network Benefit - The

Amount You Pay

Based on the

Contracted Rate

Out-of-Network Benefit

- The Amount You Pay

Based on Billed

Charges

Routine Vision Exam

or Refraction only in

lieu of a complete

exam

Once every 12 months.

$30 per exam.

Not subject to payment

of the Annual Deductible.

20% of the billed charge.

Eyeglass Lenses

Once every 12 months.

• Single Vision

50%

Not subject to payment

of the Annual Deductible.

50% of the billed charge.

• Bifocal

50%

Not subject to payment

of the Annual Deductible.

50% of the billed charge.

• Trifocal

50%

Not subject to payment

of the Annual Deductible.

50% of the billed charge.

• Lenticular

50%

Not subject to payment

of the Annual Deductible.

50% of the billed charge.

Lens Extras

• Polycarbonate

lenses

Once every 12 months.

None

Not subject to payment

of the Annual Deductible.

None

• Standard scratch-

resistant coating

Once every 12 months.

None

Not subject to payment

of the Annual Deductible.

None

Eyeglass Frames

Once every 12 months.

• Eyeglass frames

with a retail cost

up to $130.

50%

Not subject to payment

of the Annual Deductible.

50% of the billed charge.

• Eyeglass frames

with a retail cost of

$130 - 160.

50%

Not subject to payment

50% of the billed charge.

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Vision Care Service

What Is the Frequency

of Service?

Network Benefit - The

Amount You Pay

Based on the

Contracted Rate

Out-of-Network Benefit

- The Amount You Pay

Based on Billed

Charges

of the Annual Deductible.

• Eyeglass frames

with a retail cost of

$160 - 200.

50%

Not subject to payment

of the Annual Deductible.

50% of the billed charge.

• Eyeglass frames

with a retail cost of

$200 -250.

50%

Not subject to payment

of the Annual Deductible.

50% of the billed charge.

• Eyeglass frames

with a retail cost

greater than $250.

50%

Not subject to payment

of the Annual Deductible.

50% of the billed charge.

Contact Lenses and

Fitting & Evaluation

• Contact Lens

Fitting &

Evaluation

Once every 12 months.

None

Not subject to payment

of the Annual Deductible.

None

• Covered Contact

Lens Selection

Limited to a 12 month

supply.

50%

Not subject to payment

of the Annual Deductible.

50% of the billed charge.

Necessary Contact

Lenses

Limited to a 12 month

supply.

50%

Not subject to payment

of the Annual Deductible.

50% of the billed charge.

Low Vision Care

Services: Note that

Benefits for these

services will be paid as

reimbursements. When

obtaining these Vision

Care Services, you will

be required to pay all

billed charges at the time

of service. You may then

obtain reimbursement

from us. Reimbursement

will be limited to the

amounts stated.

Once every 24 months

• Low vision testing

None

20% of billed charges.

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Vision Care Service

What Is the Frequency

of Service?

Network Benefit - The

Amount You Pay

Based on the

Contracted Rate

Out-of-Network Benefit

- The Amount You Pay

Based on Billed

Charges

Not subject to payment

of the Annual Deductible.

• Low vision therapy

25% of the billed

charges.

Not subject to payment

of the Annual Deductible.

25% of billed charges.

Section 2: Pediatric Vision Exclusions

Except as may be specifically provided in this Rider under Section 1: Benefits for Pediatric Vision Care

Services, Benefits are not provided under this Rider for the following:

1. Medical or surgical treatment for eye disease which requires the services of a Physician and for

which Benefits are available as stated in the Certificate.

2. Non-prescription items (e.g. Plano lenses).

3. Replacement or repair of lenses and/or frames that have been lost or broken.

4. Optional Lens Extras not listed in Section 1: Benefits for Pediatric Vision Care Services.

5. Missed appointment charges.

6. Applicable sales tax charged on Vision Care Services.

Section 3: Claims for Pediatric Vision Care Services

When obtaining Vision Care Services from an out-of-Network Vision Care Provider, you will be required to

pay all billed charges directly to your Vision Care Provider. You may then seek reimbursement from us.

Information about claim timelines and responsibilities in the Certificate in Section 5: How to File a Claim

applies to Vision Care Services provided under this Rider, except that when you submit your claim, you

must provide us with all of the information identified below.

Written notice of sickness or injury must be provided to us within 30 days after the date when such

sickness or injury occurred. Within 15 days of receipt of such notification we will provide forms for filing

proof of loss. Failure to give notice within such time will not invalidate or reduce any claim if it was not

reasonably possible to give such notice and that notice was given as soon as was reasonably possible.

Reimbursement for Vision Care Services

To file a claim for reimbursement for Vision Care Services provided by a non-UnitedHealthcare Vision

Network Vision Care Provider, or for Vision Care Services covered as reimbursements (whether or not

provided by a UnitedHealthcare Vision Network Vision Care Provider or an out-of-Network Vision Care

Provider), you must provide all of the following information on a claim form acceptable to us:

• Your itemized receipts.

• Covered Person's name.

• Covered Person's identification number from the ID card.

• Covered Person's date of birth.

Send the above information to us:

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By mail:

Claims Department

P.O. Box 30978

Salt Lake City, UT 84130

By facsimile (fax):

248-733-6060

Section 4: Defined Terms for Pediatric Vision Care Services

The following definitions are in addition to those listed in Section 9: Defined Terms of the Certificate:

Covered Contact Lens Selection - a selection of available contact lenses that may be obtained from a

UnitedHealthcare Vision Network Vision Care Provider on a covered-in-full basis, subject to payment of

any applicable Co-payment.

UnitedHealthcare Vision Network - any optometrist, ophthalmologist, optician or other person

designated by us who provides Vision Care Services for which Benefits are available under the Policy.

Vision Care Provider - any optometrist, ophthalmologist, optician or other person who may lawfully

provide Vision Care Services.

Vision Care Service - any service or item listed in this Rider in Section 1: Benefits for Pediatric Vision

Care Services.

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Outpatient Prescription Drug Rider

UnitedHealthcare Insurance Company

This Rider to the Policy is issued to the 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 Care Services described in the Certificate.

William J Golden, President

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Introduction

Coverage Policies and Guidelines

Our Prescription Drug List (PDL) Management Committee makes tier placement changes on our behalf.

The PDL Management Committee places FDA-approved Prescription Drug Product into tiers by

considering a number of factors including clinical and economic factors. Clinical factors may include

review of the place in therapy or use as compared to other similar product or services, site of care,

relative safety or effectiveness of the Prescription Drug Product, as well as if certain supply limits or prior

authorization requirements should apply. Economic factors may include the Prescription Drug Product's

total cost including any rebates and evaluations of the cost effectiveness of the Prescription Drug

Product.

Some Prescription Drug Products are more cost effective for treating specific conditions as compared to

others; therefore, a Prescription Drug Product may be placed on multiple tiers according to the condition

for which the Prescription Drug Product was prescribed to treat, or according to whether it was prescribed

by a Specialist.

We may, from time to time, change the placement of a Prescription Drug Product among the tiers. These

changes generally will happen quarterly, but no more than six times per calendar year. These changes

may happen 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 you is a determination that is made by you and

your prescribing Physician.

NOTE: The tier placement of a Prescription Drug Product may change, from time to time, 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 contact us at www.myuhc.com or the telephone number on your ID

card for the most up-to-date tier placement.

Notice of Adverse Change to the Prescription Drug List

We will provide at least 60 days' written notice of an adverse change to the Prescription Drug List, less

than 60 days' notice is allowed when a drug is being removed from the Prescription Drug List due to

safety concerns.

"Adverse change to the Prescription Drug List" means a change that removes a Prescription Drug

Product currently prescribed for you from the Prescription Drug List applicable to your health plan or a

change that moves the Prescription Drug Product to a tier with a higher cost-sharing requirement.

The notice will inform you of the change and advise you to consult with your provider about the change. If

a Prescription Drug Product is removed from the Prescription Drug List, we will notify you of the ability to

request an exception and provide a form for requesting the exception.

If you have already received prior authorization for the Prescription Drug Product, we will continue to

honor the authorization until it expires, as long as you continue to be covered under the same plan and

the Prescription Drug Product has not been removed from the Prescription Drug List due to safety

concerns.

If a Prescription Drug Product has been removed from the Prescription Drug List (except if removed due

to safety concerns), and an exception request is received prior to the effective date of the change, we will

continue to cover the Prescription Drug Product until a decision is reached on the exception request.

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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 must 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 did not 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 Co-payment and/or Co-insurance, Ancillary Charge and any

deductible that applies.

Submit your claim to:

Optum Rx

PO Box 650629

Dallas, TX 75265-0629

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 choose not to obtain your Prescription Drug Product from the

Designated Pharmacy, you may opt-out of the Designated Pharmacy program by contacting us at

www.myuhc.com or the telephone number on your ID card. If you want to opt-out of the program and fill

your Prescription Drug Product at a non-Designated Pharmacy but do not inform us, you will be

responsible for the entire cost of the Prescription Drug Product and no Benefits will be paid.

If you are directed to a Designated Pharmacy and you have informed us of your decision not to obtain

your Prescription Drug Product from a Designated Pharmacy, you will be subject to the out-of-Network

Benefit for that Prescription Drug Product. For a Specialty Prescription Drug Product, if you choose to

obtain your Specialty Prescription Drug Product at a Non-Preferred Specialty Network Pharmacy, you will

be subject to the Non-Preferred Specialty Network Pharmacy Co-payment and/or Co-insurance.

Smart Fill Program - Split Fill

Certain Specialty Prescription Drug Products may be dispensed by the Designated Pharmacy in 15-day

supplies up to 90 days and at a pro-rated Co-payment or Co-insurance. You will receive a 15-day supply

of their Specialty Prescription Drug Product to find out if you will tolerate the Specialty Prescription Drug

Product prior to purchasing a full supply. The Designated Pharmacy will contact you each time prior to

dispensing the 15-day supply to confirm if you are tolerating the Specialty Prescription Drug Product. You

may find a list of Specialty Prescription Drug Products included in the Smart Fill Program, by contacting

us at www.myuhc.com or the telephone number on your ID card.

Smart Fill Program - 90-Day Supply

Certain Specialty Prescription Drug Products may be dispensed by the Designated Pharmacy in 90-day

supplies. The Co-payment and/or Co-insurance will reflect the number of days dispensed. The Smart Fill

Program offers a 90-day supply of certain Specialty Prescription Drug Products if you are stabilized on a

Specialty Prescription Drug Product included in the Smart Fill Program. You may find a list of Specialty

Prescription Drug Products included in the Smart Fill Program, by contacting us at www.myuhc.com or

the telephone number on your ID card.

When Do We Limit 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 choice of Network Pharmacies may be limited. If this happens, we may require

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you to choose one Network Pharmacy that will provide and coordinate all future pharmacy services.

Benefits will be paid only if you use the chosen Network Pharmacy. If you don't make a choice within 31

days of the date we notify you, we will choose a Network Pharmacy for you.

Rebates and Other Payments

We may receive rebates for certain drugs included on the Prescription Drug List, including those drugs

that you purchase prior to meeting any applicable deductible. As determined by us, we may pass a

portion of these rebates on to you. When rebates are passed on to you, they may be taken into account in

determining your Co-payment and/or Co-insurance.

We, and a number of our affiliated entities, conduct business with 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 or provide other communications to you, your Physician, or your

pharmacy that communicate a variety of messages, including information about Prescription and non-

prescription Drug Products. These communications may include offers that enable you, as you determine,

to purchase the described product at a discount. In some instances, non-UnitedHealthcare entities may

support and/or provide content for these communications and offers. Only you and your Physician can

determine whether a change in your Prescription and/or non-prescription Drug regimen 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 taking part in health

management programs. You may access information on these programs by contacting us at

www.myuhc.com or the telephone number on your ID card.

Maintenance Medication Program

If you require certain Maintenance Medications, we may direct you to the Mail Order Network Pharmacy

or Preferred 90 Day Retail Network Pharmacy to obtain those Maintenance Medications. If you choose

not to obtain your Maintenance Medications from the Mail Order Network Pharmacy or Preferred 90 Day

Retail Network Pharmacy, you may opt-out of the Maintenance Medication Program by contacting us at

www.myuhc.com or the telephone number on your ID card. If you choose to opt out when directed to a

Mail Order Network Pharmacy or Preferred 90 Day Retail Network Pharmacy but do not inform us, you

will be subject to the out-of-Network Benefit for that Prescription Drug Product after the allowed number of

fills at a Retail Network Pharmacy.

Prescription Drug Products Prescribed by a Specialist

You may receive an enhanced or reduced Benefit, or no Benefit, based on whether the Prescription Drug

Product was prescribed by a Specialist. You may access information on which Prescription Drug Products

are subject to Benefit enhancement, reduction or no Benefit by contacting us at www.myuhc.com or the

telephone number on your ID card.

Continuity of Prescriptions

If you have been receiving a prescription drug based on a prior authorization from another insurer, and

your coverage with that insurer has been replaced with coverage under this Policy, we will honor your

prior insurer's prior authorization of the prescription drug, for a period not to exceed six months, until we

have the opportunity to conduct a review with your prescribing provider. We are not required to provide

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benefits under this section for conditions or services not otherwise covered under this Policy and your

Cost-Sharing responsibility will be based on any applicable Co-payment, Co-insurance or deductible

requirements of the Policy.

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Outpatient Prescription Drug Rider Table of Contents

Section 1: Benefits for Prescription Drug Products ...........................180

Section 2: Exclusions ............................................................................182

Section 3: Defined Terms ......................................................................185

Section 4: Your Right to Request an Exclusion Exception ................188

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Section 1: Benefits for Prescription Drug Products

Benefits are available for Prescription Drug Products at either a Network Pharmacy or an out-of-Network

Pharmacy and are subject to Co-payments and/or Co-insurance or other payments that vary depending

on which of the tiers of the Prescription Drug List the Prescription Drug Product is placed. Refer to the

Outpatient Prescription Drug Schedule of Benefits for applicable Co-payments and/or Co-insurance

requirements.

Benefits for Prescription Drug Products are available when the Prescription Drug Product meets the

definition of a Covered Health Care Service

Prescription Drug Products as Part of a Clinical Trial

Benefits are provided for outpatient Prescription Drug Products provided as part of an approved clinical

trial if the following conditions are met:

• You have a life-threatening illness (one which is likely to cause death within one year) for which no

standard treatment is effective.

• You are eligible to participate according to the clinical trial protocol with respect to such illness.

• Your participation in the trial offers meaningful potential for significant clinical benefit to you.

• Your referring Physician has concluded that your participation in such a trial would be appropriate

based upon the satisfaction of the above conditions. Refer to Clinical Trials in Section 1: Covered

Health Care Services in your Certificate for details of coverage.

Early Refills of Prescription Eye Drops

Benefits are provided for one early refill of a Prescription Order or Refill for eye drops when the following

criteria are met:

• You request the refill no earlier than the date on which 70% of the days of use authorized by the

prescribing health care provider have elapsed.

• The prescribing health care provided indicated on the original prescription that a specific number of

refills are authorized.

• The refill requested does not exceed the number of refills indicated on the original Prescription

Order or Refill.

• The Prescription Drug Product has not been refilled more than once during the period authorized

by the prescribing health care provider prior to the request for early refill.

• The prescription eye drops are a covered benefit under the plan.

Your Cost-Sharing responsibility will be based on any applicable Co-payment, Co-insurance or deductible

requirements of the Policy.

Abuse-Deterrent Opioid Analgesic Prescription Drug Products

Benefits are provided for Abuse-Deterrent Opioid Analgesic Prescription Drug Products and will be no

less favorable than Benefits for opioid analgesic Prescription Drug Products that are not abuse-deterrent

and that are covered under this Policy.

Refill Synchronization

We have a procedure to align the refill dates of Prescription Drug Products so that Prescription Drug

Products that are refilled at the same frequency can be refilled concurrently. You may access

information on these procedures through the Internet at [www.myuhc.com] or by calling the telephone

number on your ID card.

Specialty Prescription Drug Products

Benefits are provided for Specialty Prescription Drug Products.

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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 have informed us of your decision not to obtain

your Specialty Prescription Drug Product from a Designated Pharmacy, and you choose to obtain your

Specialty Prescription Drug Product at a Non-Preferred Specialty Network Pharmacy, you will be subject

to the Non-Preferred Specialty Network Co-payment and/or Co-insurance for that Specialty Prescription

Drug Product.

Please see Section 3: Defined Terms for a full description of Specialty Prescription Drug Product and

Designated Pharmacy.

The Outpatient Prescription Drug Schedule of Benefits will tell you how Specialty Prescription Drug

Product supply limits apply.

Prescription Drugs from a Retail Network Pharmacy

Benefits are provided for Prescription Drug Products dispensed by a retail Network Pharmacy.

The Outpatient Prescription Drug Schedule of Benefits will tell you how retail Network Pharmacy supply

limits apply.

Depending upon your plan design, this Outpatient Prescription Drug Rider may offer limited Network

Pharmacy providers. You can confirm that your pharmacy is a Network Pharmacy by calling the

telephone number on your ID card or you can access a directory of Network Pharmacies online at

www.myuhc.com.

Prescription Drugs from a Retail Out-of-Network Pharmacy

Benefits are provided for Prescription Drug Products dispensed by a retail out-of-Network Pharmacy.

If the Prescription Drug Product is dispensed by a retail out-of-Network Pharmacy, you must pay for the

Prescription Drug Product at the time it is dispensed. You can file a claim for reimbursement with us, as

described in your Certificate, Section 5: How to File a Claim. We will not reimburse you for the difference

between the Out-of-Network Reimbursement Rate and the out-of-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 an out-of-Network

Pharmacy.

The Outpatient Prescription Drug Schedule of Benefits will tell you how retail out-of-Network Pharmacy

supply limits apply.

Prescription Drug Products from a Mail Order Network Pharmacy or Preferred 90 Day Retail

Network Pharmacy

Benefits are provided for certain Prescription Drug Products dispensed by a mail order Network

Pharmacy or Preferred 90 Day Retail Network Pharmacy.

The Outpatient Prescription Drug Schedule of Benefits will tell you how mail order Network Pharmacy and

Preferred 90 Day Retail Network Pharmacy supply limits apply.

Please contact us at www.myuhc.com or the telephone number on your ID card to find out 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 or Preferred 90 Day Retail Network Pharmacy.

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Section 2: Exclusions

Exclusions from coverage listed in the Certificate also apply to this Rider. In addition, the exclusions listed

below apply.

When an exclusion applies to only certain Prescription Drug Products, you can contact us at

www.myuhc.com or 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 treatments for specific diseases and/or dosage regimens determined by us to be

experimental, investigational or unproven.

This exclusion does not apply to the off-label use of a Prescription Drug Product prescribed to treat

cancer, HIV or AIDS if such Prescription Drug Product is recognized for treatment in any of the

standard reference compendia.

This exclusion does not apply to outpatient Prescription Drug Products provided as part of an

approved clinical trial as described in Clinical Trials in Section 1: Covered Health Care Services in

your Certificate.

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. This exclusion does not apply if your workers' compensation claim has been controverted

and you are awaiting a Workers' Compensation Board determination.

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 includes certain

forms of vaccines/immunizations.

10. Durable Medical Equipment, including insulin pumps and related supplies for the management and

treatment of diabetes, for which Benefits are provided in your Certificate. Prescribed and non-

prescribed outpatient supplies. This does not apply to 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.

▪ Single entity vitamins.

12. Certain unit dose packaging or repackagers of Prescription Drug Products.

13. Medications used for cosmetic purposes.

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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 Care 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. This exclusion does not apply to

Prescription Drug Products prescribed to treat Iatrogenic Infertility and Preimplantation Genetic

Testing (PGT) as described in the Certificate.

17. Certain Prescription Drug Products for tobacco cessation that exceed the minimum number of

drugs required to be covered under the Patient Protection and Affordable Care Act (PPACA) in

order to comply with essential health benefits requirements.

18. Prescription Drug Products not placed on Tier 1, Tier 2, Tier 3 or Tier 4 of the Prescription Drug List

at the time the Prescription Order or Refill is dispensed. We have developed a process for

reviewing Benefits for a Prescription Drug Product that is not on an available tier of the Prescription

Drug List, but that has been prescribed as a Medically Necessary alternative. For information about

this process, call the telephone number on your ID card.

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 made up 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 or supplement. Such determinations may be made up to six times during a calendar

year. 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 placed on 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, and prescription medical food products even when used for the treatment

of Sickness or Injury except as described under Medical Foods and Infant Formulas in Section 1:

Covered Health Care Services in your Certificate.

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. 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. 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 for which there are Therapeutically Equivalent alternatives

available, unless otherwise required by law or approved by us. Such determinations may be made

up to six times during a calendar year. We may decide at any time to reinstate Benefits for a

Prescription Drug Product that was previously excluded under this provision.

26. Certain Prescription Drug Products that have not been prescribed by a Specialist.

27. A Prescription Drug Product that contains marijuana, including medical marijuana.

28. Certain Prescription Drug Products that exceed the minimum number of drugs required to be

covered under the Patient Protection and Affordable Care Act (PPACA) essential health benefit

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requirements in the applicable United States Pharmacopeia category and class or applicable state

benchmark plan category and class.

29. Dental products, including but not limited to prescription fluoride topicals.

30. A Prescription Drug Product with either:

▪ An approved biosimilar.

▪ A biosimilar and Therapeutically Equivalent to another covered Prescription Drug Product.

For the purpose of this exclusion a "biosimilar" is a biological Prescription Drug Product approved

based on both of the following:

▪ It is highly similar to a reference product (a biological Prescription Drug Product).

▪ It has no clinically meaningful differences in terms of safety and effectiveness from the

reference product.

Such determinations may be made up to six times during a calendar year. We may decide at any

time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this

provision.

31. Diagnostic kits and products, including associated services.

32. Publicly available software applications and/or monitors that may be available with or without a

Prescription Order or Refill.

33. Certain Prescription Drug Products that are FDA approved as a package with a device or

application, including smart package sensors and/or embedded drug sensors. This exclusion does

not apply to a device or application that assists you with the administration of a Prescription Drug

Product.

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Section 3: Defined Terms

Abuse-Deterrent Opioid Analgesic Drug Product - a Brand-name or Generic Opioid Analgesic Drug

Product approved by the federal Food and Drug Administration with abuse-deterrent labeling claims that

indicate the drug product is expected to result in a meaningful reduction in abuse.

Ancillary Charge - a charge, in addition to the Co-payment and/or Co-insurance, that you must 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.

For Prescription Drug Products from Network Pharmacies, the Ancillary Charge is the difference between:

• The Prescription Drug Charge for the Prescription Drug Product.

• The Prescription Drug Charge for the Chemically Equivalent Prescription Drug Product.

For Prescription Drug Products from out-of-Network Pharmacies, the Ancillary Charge is the difference

between:

• The Out-of-Network Reimbursement Rate for the Prescription Drug Product.

• The Out-of-Network Reimbursement Rate for the Chemically Equivalent Prescription Drug Product.

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. This includes data sources such as Medi-Span, that classify drugs as either

brand or generic based on a number of factors. Not all products identified as a "brand name" by the

manufacturer, pharmacy, or your Physician will be classified as Brand-name by us.

Chemically Equivalent - when Prescription Drug Products contain the same active ingredient.

Cost-Sharing - any coverage limit, Co-payment, Co-insurance, deductible or other out-of-pocket expense

associated with a health plan.

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. This includes Specialty

Prescription Drug Products. Not all Network Pharmacies are Designated Pharmacies.

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. This includes data sources such as

Medi-Span, that classify drugs as either brand or generic based on a number of factors. Not all products

identified as a "generic" by the manufacturer, pharmacy or your Physician will be classified as a Generic

by us.

List of Preventive Medications - a list that identifies certain Prescription Drug Products, which may

include certain Specialty Prescription Drug Products, on the Prescription Drug List that are intended to

reduce the likelihood of Sickness. You may find the List of Preventive Medications by contacting us at

www.myuhc.com or the telephone number on your ID card.

List of Zero Cost Share Medications - a list that identifies certain Prescription Drug Products on the

Prescription Drug List that are available at zero cost share (no cost to you) when obtained from a retail

Network Pharmacy. Certain Prescription Drug Products on the List of Zero Cost Share Medications may

be available at a mail order Network Pharmacy. You may find the List of Zero Cost Share Medications by

contacting us at www.myuhc.com or the telephone number on your ID card.

Maintenance Medication - a Prescription Drug Product expected to be used for six months or more to

treat or prevent a chronic condition. You may find out if a Prescription Drug Product is a Maintenance

Medication by contacting us at www.myuhc.com or the telephone number on your ID card.

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.

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• 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 placed on a tier by our PDL Management Committee.

• December 31st of the following calendar year.

Non-Preferred Specialty Network Pharmacy - a specialty pharmacy that we identify as a non-preferred

pharmacy within the Network.

Opioid Analgesic Drug Product - a Brand-name or generic drug product in the opioid analgesic drug

class prescribed to treat moderate to severe pain or other conditions, whether in the immediate release or

extended release, long-acting form and whether or not combined with other drug substances to form a

single drug product or dosage form.

Out-of-Network Reimbursement Rate - the amount we will pay to reimburse you for a Prescription Drug

Product that is dispensed at an out-of-Network Pharmacy. The Out-of-Network Reimbursement Rate for a

particular Prescription Drug Product dispensed at an out-of-Network Pharmacy includes a dispensing fee

and any applicable sales tax.

PPACA - Patient Protection and Affordable Care Act of 2010.

PPACA Zero Cost Share 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 Prescription Drug Charge (without application of any Co-payment, Co-insurance, Annual Deductible,

or Annual Drug 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, such as Human

Immunodeficiency Virus (HIV) prevention drugs.

• 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

including all FDA -approved methods of female contraception, including over the counter products..

You may find out if a drug is a PPACA Zero Cost Share Preventive Care Medication as well as

information on access to coverage of Medically Necessary alternatives by contacting us at

www.myuhc.com or the telephone number on your ID card.

Preferred 90 Day Retail Network Pharmacy - a retail pharmacy that we identify as a preferred

pharmacy within the Network for Maintenance Medication.

Preferred Specialty Network Pharmacy - a specialty pharmacy that we identify as a preferred pharmacy

within the Network.

Prescription Drug Charge - the rate we have agreed to pay our Network Pharmacies for a Prescription

Drug Product dispensed at a Network Pharmacy. The rate includes any applicable dispensing fee and

sales tax.

Prescription Drug List - a list that places into tiers medications or products that have been approved by

the U.S. Food and Drug Administration (FDA). This list is subject to our review and change from time to

time. You may find out to which tier a particular Prescription Drug Product has been placed by contacting

us at www.myuhc.com or the telephone number on your ID card.

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Prescription Drug List (PDL) Management Committee - the committee that we designate for placing

Prescription Drug Products into specific tiers.

Prescription Drug Product - a medication or product that has been approved by the U.S. Food and Drug

Administration (FDA) and that can, under federal or state law, be dispensed only according to a

Prescription Order or Refill. A Prescription Drug Product includes a medication that is generally

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.

• Oral hypoglycemic agents.

• Certain vaccines/immunizations administered at a Network Pharmacy.

• Certain injectable medications administered at a Network Pharmacy.

• 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 meters, including continuous 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 allows issuing such a directive.

Specialty Prescription Drug Product - Prescription Drug Products that are generally high cost, self-

administered biotechnology drugs used to treat patients with certain illnesses. Specialty Prescription Drug

Products include certain drugs for fertility preservation and Preimplantation Genetic Testing (PGT) for

which Benefits are described in the Certificate under Fertility Preservation for Iatrogenic Infertility and

Preimplantation Genetic Testing (PGT) and Related Services in Section 1: Covered Health Care

Services. Specialty Prescription Drug Products may include drugs on the List of Preventive Medications.

You may access a complete list of Specialty Prescription Drug Products by contacting us at

www.myuhc.com or the telephone number on your ID card.

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. This fee includes any

applicable dispensing fee and sales tax.

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Section 4: Your Right to Request an Exclusion

Exception

When a Prescription Drug Product is excluded from coverage, you or your representative may request an

exception to gain access to the excluded Prescription Drug Product. To make a request, contact us in

writing or call the toll-free number on your ID card. We will notify you of our determination within 72 hours

or two business days of receipt of the request, whichever is less.

Please note, if your request for an exception is approved by us, you may be responsible for paying the

applicable Co-payment and/or Co-insurance based on the Prescription Drug Product tier placement, or at

the highest tier as described in the Benefit Information table in the Outpatient Prescription Drug Schedule

of Benefits, in addition to any applicable Ancillary Charge.

Exigent Requests

If your request requires immediate action and a delay could significantly increase the risk to your health,

or the ability to regain maximum function, call us as soon as possible. We will provide a written or

electronic determination within 24 hours. If coverage approved, we will cover the Prescription Drug

Product for the duration of the exigency.

External Review

If you are not satisfied with our determination of your exclusion exception request, you may be entitled to

request an external review. You or your representative may request an external review by sending a

written request to us to the address set out in the determination letter or by calling the toll-free number on

your ID card. The Independent Review Organization (IRO) will notify you of our determination within 72

hours or two business days of receipt of the request, whichever is less.

Expedited External Review

If you are not satisfied with our determination of your exclusion exception request and it involves an

urgent situation, you or your representative may request an expedited external review by calling the toll-

free number on your ID card or by sending a written request to the address set out in the determination

letter. The IRO will notify you of our determination within 24 hours.

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Outpatient Prescription Drug

UnitedHealthcare Insurance Company

Schedule of Benefits

When Are Benefits Available for Prescription Drug Products?

Benefits are available for Prescription Drug Products at either a Network Pharmacy or an out-of-Network

Pharmacy and are subject to Co-payments and/or Co-insurance or other payments that vary depending

on which of the tiers of the Prescription Drug List the Prescription Drug Product is placed.

The Prescription Drug List categorizes medications, products or devices that have been approved by the

U.S. Food and Drug Administration into tiers. The Prescription Drug List is subject to our periodic review

and modification (generally quarterly, but no more than six times per calendar year). Please contact us at

[www.myuhc.com] or the telephone number on your ID card for the most up-to-date tier placement.

Benefits for Prescription Drug Products are available when the Prescription Drug Product meets the

definition of a Covered Health Care Service

Orally Administered Cancer Therapy

Benefits are provided for orally administered anticancer Prescription Drug Products from a retail or mail

order Network Pharmacy at an equivalent level to that of intravenously administered or injected

anticancer medication, regardless of tier placement. This includes orally administered anticancer

medications that are Specialty Prescription Drug Products.

What Happens When 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. Therefore your Co-payment and/or Co-insurance

may change and an Ancillary Charge may apply, or you will no longer have Benefits for that particular

Brand-name Prescription Drug Product.

What Happens When a Biosimilar Product Becomes Available for a

Reference Product?

If a biosimilar becomes available for a reference product (a biological Prescription Drug Product), the tier

placement of the reference product may change. Therefore, your Co-payment and/or Co-insurance may

change and an Ancillary Charge may apply, or you will no longer have Benefits for that particular

reference product.

How Do Supply Limits Apply?

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 Co-payment and/or Co-insurance,

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.

Supply limits are subject, from time to time, to our review and change. This may limit 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.

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You may find out whether a Prescription Drug Product has a supply limit for dispensing by contacting us

at www.myuhc.com or the telephone number on your ID card.

Dispensing an Emergency Supply of Chronic Maintenance Drugs

A pharmacist may dispense an emergency supply of a chronic maintenance drug to a patient without a

prescription if the pharmacist is unable to obtain authorization to refill the prescription from a health care

provider and the pharmacist has a record of the prescription in the name of the patient, including the

amount of the drug dispensed in the most recent prescription or the standard unit of dispensing the drug,

and that record does not indicate that no emergency supply is permitted. A pharmacist may dispense an

emergency supply of a chronic maintenance drug to a patient as long as the following conditions are met:

• The drug dispensed may not be a controlled substance included in Schedules I and II under the

federal Controlled Substances Act.

• The amount dispensed may not exceed a 30-day supply or, if the standard unit of dispensing

exceeds a 30-day supply, may not exceed the smallest standard unit of dispensing, except that, if

the drug is included on Schedule III or IV of the federal Controlled Substances Act, the amount

dispensed may not exceed a 7-day supply

• The pharmacist may not dispense the chronic maintenance drug in an emergency supply to the

same patient more than twice in a 12-month period.

• The pharmacist must determine, in the pharmacist's professional judgment, that the prescription is

essential to sustain the life of the patient or to continue therapy for a chronic condition of the patient

and that failure to dispense the drug could reasonably produce undesirable health consequences

or cause physical or mental discomfort.

"Chronic maintenance drug" means a medication prescribed to treat a chronic, long-term condition and

that is taken on a regular, recurring basis.

Prescription Drug Coverage During A State of Emergency

We shall provide coverage for the furnishing or dispensing of a Prescription Drug Product in accordance

with a valid prescription issued by a Provider in a quantity sufficient for an extended period of time, not to

exceed a 180-day supply, during a statewide state of emergency declared by the Governor in accordance

with Title 37-B, section 742. This does not apply to coverage of prescribed contraceptive supplies

furnished and dispensed pursuant to Section 2756, 2847-G or 4247 or coverage of opioids prescribed in

accordance with limits set forth in Title 32.

Do Prior Authorization Requirements Apply?

Before certain Prescription Drug Products are dispensed to you, 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 Care 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.

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.

Out-of-Network Pharmacy Prior Authorization

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When Prescription Drug Products are dispensed at an out-of-Network Pharmacy, you or your

Physician are responsible for obtaining prior authorization from us as required.

Prior authorization will not be required for at least one Prescription Drug Product for treatment of opioid

use disorder in each therapeutic class of medication used in medication-assisted treatment. Prior

authorization will not be required for medication-assisted treatment for opioid use disorder for Covered

Persons who are Pregnant.

Prior authorizations will not be denied for Prescription Drug Products on the Prescription Drug List that is

prescribed to assess or treat a serious mental illness. A "serious mental illness" means a mental disorder,

as defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric

Association, that results in serious functional impairment that substantially interferes with or limits one or

more major life activities.

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, from time to time, to our review and change. There may be certain Prescription

Drug Products that require you to notify us directly rather than your Physician or pharmacist. You may find

out whether a particular Prescription Drug Product requires notification/prior authorization by contacting

us at www.myuhc.com or 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 an out-of-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

Out-of-Network Reimbursement Rate (for Prescription Drug Products from an out-of-Network Pharmacy),

less the required Co-payment and/or Co-insurance, 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 Care Service or it

is an Experimental or Investigational or Unproven Service.

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 related to such programs. You may access

information on available programs and any applicable prior authorization, participation or activation

requirements related to such programs by contacting us at www.myuhc.com or the telephone number on

your ID card.

We will accept and respond to prior authorization requests through a secure electronic transmission using

standards recommended by a national institute for the development of fair standards and adopted by a

national council for prescription drug programs for electronic prescribing transactions. Transmission of a

facsimile through a proprietary payer portal or by use of an electronic form is not considered electronic

transmission.

Does Step Therapy Apply?

Certain Prescription Drug Products for which Benefits are described under this Prescription Drug Rider

are subject to step therapy requirements. In order to receive Benefits for such Prescription Drug Products

you must use a different Prescription Drug Product(s) first.

Clinical review criteria used to establish a step therapy protocol will be based on clinical practice

guidelines that:

• Recommend that the Prescription Drug Products be taken in the specific sequence required by the

step therapy protocol.

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• Are developed and endorsed by a multidisciplinary panel of experts that manages conflicts of

interest among the members of the writing and review groups by:

▪ Requiring members to disclose any potential conflicts of interest with entities, including

carriers and pharmaceutical manufacturers, and recuse themselves from voting if they have

a conflict of interest.

▪ Using a methodologist to work with writing groups to provide objectivity in data analysis and

ranking of evidence through the preparation of evidence tables and facilitating consensus.

▪ Offering opportunities for public review and comments.

• Are based on high-quality studies, research and medical practice.

• Are created by an explicit and transparent process that:

▪ Minimizes biases and conflicts of interest.

▪ Explains the relationship between treatment options and outcomes.

▪ Rates the quality of the evidence supporting recommendations.

▪ Considers relevant patient subgroups and preferences.

▪ Are continually updated through a review of new evidence, research and newly developed

treatments.

In the absence of clinical practice guidelines that meet the above requirements, peer-reviewed

publications may be substituted.

Prescription Drug Products on the Prescription Drug List that are prescribed to assess or treat a serious

mental illness will be approved. Prescription Drugs on the Prescription Drug List that are prescribed for a

serious mental illness will not require Step Therapy.

Exceptions process. When coverage of a Prescription Drug Product for the treatment of any medical

condition is restricted for use by us or a utilization review organization through the use of a step therapy

protocol, the Covered Person and the prescriber must have access to a clear, readily accessible and

convenient process to request a step therapy override exception determination from us or the utilization

review organization.

• We or the utilization review organization may use the existing medical exceptions process to

provide step therapy override exception determinations, and the process established must be

easily accessible on our or the utilization review organization's website.

• We or the utilization review organization shall expeditiously grant a step therapy override exception

determination if:

▪ The required prescription drug is contraindicated or will likely cause an adverse reaction in or

physical or mental harm to the Covered Person.

▪ The required Prescription Drug Product is expected to be ineffective based on the known

clinical characteristics of the Covered Person and the known characteristics of the

Prescription Drug Product regimen.

▪ The Covered Person has tried the required Prescription Drug Product while under the

Covered Person's current or previous health insurance or health plan, or another

Prescription Drug Product in the same pharmacologic class or with the same mechanism of

action, and the Prescription Drug Product was discontinued due to lack of efficacy or

effectiveness, diminished effect or an adverse reaction.

▪ The required Prescription Drug Product is not in the best interest of the Covered Person,

based on Medical Necessity.

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▪ The Covered Person is stable on a Prescription Drug Product selected by the Covered

Person's health care provider for the medical condition under consideration while on a

current or previous health insurance or health plan.

Nothing in this paragraph may be construed to encourage the use of a pharmaceutical sample for

the sole purpose of meeting the requirements for the granting of a step therapy override exception

determination.

• Upon the granting of a step therapy override exception determination, we or the utilization review

organization shall authorize coverage for the Prescription Drug Product prescribed by the

prescriber.

• Unless exigent circumstances exist, we or the utilization review organization shall grant or deny a

request for a step therapy override exception determination or an appeal of a determination within

72 hours, or 2 business days, whichever is less, after receipt of the request.

If exigent circumstances exist, we or the utilization review organization shall grant or deny the

request within 24 hours after receipt of the request. We shall provide coverage for the Prescription

Drug Product prescribed by the prescriber during the pendency of the request for a step therapy

override exception determination or an appeal of a determination. If we or the utilization review

organization do not grant or deny the request within the time required under this paragraph, the

exception or appeal is granted.

Exigent circumstances exist when a Covered Person is suffering from a health condition that may

seriously jeopardize the Covered Person's life, health or ability to regain maximum function or

when an enrollee is undergoing a current course of treatment using a nonformulary drug.

• A Covered Person may appeal a step therapy override exception determination.

• This section does not prevent:

▪ Us or the utilization review organization from requiring a Covered Person to try a generic

drug, as defined in 32 M.R.S. § 13702-A(14), or an interchangeable biological product, as

defined in 32 M.R.S. § 13702-A(14-A), prior to providing coverage for the equivalent brand-

name Prescription Drug Product.

▪ A health care provider from prescribing a Prescription Drug Product that is determined to be

Medically Necessary.

You may find out whether a Prescription Drug Product is subject to step therapy requirements by

contacting us at www.myuhc.com or the telephone number on your ID card.

What Do You Pay?

You are responsible for paying the applicable Co-payment and/or Co-insurance described in the Benefit

Information table, in addition to any Ancillary Charge. You are not responsible for paying a Co-payment

and/or Co-insurance for PPACA Zero Cost Share Preventive Care Medications. You are not responsible

for paying a Co-payment and/or Co-insurance for Prescription Drug Products on the List of Zero Cost

Share 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 Equivalent. An Ancillary Charge does not

apply to any Out-of-Pocket Limit.

The amount you pay for any of the following under this Rider will not be included in calculating any Out-

of-Pocket Limit stated in your Certificate:

• Ancillary Charges.

• Any amount you pay for Prescription Drug Products for Iatrogenic Infertility and Preimplantation

Genetic Testing (PGT) that exceeds the Maximum Policy Benefit.

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• The difference between the Out-of-Network Reimbursement Rate and an out-of-Network

Pharmacy's Usual and Customary Charge for a Prescription Drug Product.

• 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. Our contracted rates (our Prescription

Drug Charge) will not be available to you.

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Payment Information

Payment Term And Description

Amounts

Iatrogenic Infertility and Preimplantation

Genetic Testing (PGT) Maximum Policy Benefit

The maximum amount we will pay for any

combination of covered Prescription Drug Products

for Iatrogenic Infertility and Preimplantation Genetic

Testing (PGT) during the entire period of time you

are enrolled for coverage under the Policy.

$5,000 per Covered Person.

Co-payment and Co-insurance

Co-payment

Co-payment for a Prescription Drug Product at a

Network or out-of-Network Pharmacy is a specific

dollar amount.

Co-insurance

Co-insurance for a Prescription Drug Product at a

Network Pharmacy is a percentage of the

Prescription Drug Charge.

Co-insurance for a Prescription Drug Product at an

out-of-Network Pharmacy is a percentage of the

Out-of-Network Reimbursement Rate.

Co-payment and Co-insurance

Your Co-payment and/or Co-insurance is

determined by the Prescription Drug List (PDL)

Management Committee's tier placement of a

Prescription Drug Product.

We may cover multiple Prescription Drug Products

for a single Co-payment and/or Co-insurance if the

combination of these multiple products provides a

therapeutic treatment regimen that is supported by

available clinical evidence. You may determine

whether a therapeutic treatment regimen qualifies

for a single Co-payment and/or Co-insurance by

contacting us at www.myuhc.com or the telephone

number on your ID card.

Your Co-payment and/or Co-insurance may be

reduced when you participate in 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 these programs and

any applicable prior authorization, participation or

activation requirements associated with such

programs by contacting us at www.myuhc.com or

For Prescription Drug Products at a retail Network

Pharmacy, you are responsible for paying the

lowest of the following:

• The applicable Co-payment and/or Co-

insurance.

• The Network Pharmacy's Usual and

Customary Charge for the Prescription Drug

Product.

• The Prescription Drug Charge for that

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 Co-payment and/or Co-

insurance.

• The Prescription Drug Charge for that

Prescription Drug Product.

See the Co-payments and/or Co-insurance stated

in the Benefit Information table for amounts.

You are not responsible for paying a Co-payment

and/or Co-insurance for PPACA Zero Cost Share

Preventive Care Medications.

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Payment Term And Description

Amounts

the telephone number on your ID card.

Your Co-payment and/or Co-insurance for insulin

will not exceed the amount allowed by applicable

law.

For insulin Prescription Drug Products on any tier,

the total amount of deductibles, Co-payments, Co-

insurance or other cost sharing requirements shall

not exceed $35 per prescription up to a 30-day

supply, regardless of the amount of insulin needed

to fill your insulin prescriptions.

Special Programs: We may have certain

programs in which you may receive a reduced or

increased Co-payment and/or Co-insurance 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 by

contacting us at www.myuhc.com or the telephone

number on your ID card.

Co-payment/Co-insurance Waiver Program: If

you are taking certain Prescription Drug Products,

including, but not limited to, Specialty Prescription

Drug Products, and you move to certain lower tier

Prescription Drug Products or Specialty

Prescription Drug Products, we may waive your Co-

payment and/or Co-insurance for one or more

Prescription Orders or Refills.

Prescription Drug Products Prescribed by a

Specialist: You may receive a reduced or

increased Co-payment and/or Co-insurance based

on whether the Prescription Drug Product was

prescribed by a Specialist. You may access

information on which Prescription Drug Products

are subject to a reduced or increased Co-payment

and/or Co-insurance by contacting us at

www.myuhc.com or the telephone number on your

ID card.

NOTE: The tier status of a Prescription Drug

Product can change from time to time. These

changes generally happen quarterly but no more

than six times per calendar year, based on the PDL

Management Committee's tiering decisions. When

that happens, you may pay more or less for a

Prescription Drug Product, depending on its tier

placement. Please contact us at www.myuhc.com

or the telephone number on your ID card for the

most up-to-date tier status.

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Benefit Information

The amounts you are required to pay as shown below in the Outpatient Prescription Drug

Schedule of Benefits are based on the Prescription Drug Charge for Network Benefits and the

Out-of-Network Reimbursement Rate for out-of-Network Benefits. For out-of-Network Benefits,

you are responsible for the difference between the Out-of-Network Reimbursement Rate and the

out-of-Network Pharmacy's Usual and Customary Charge.

Description and Supply Limits

What Is the Co-payment or Co-

insurance You Pay?

This May Include a Co-payment, Co-insurance

or Both

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, or as allowed

under the Smart Fill Program.

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 Co-payment and/or Co-insurance that applies

will reflect the number of days dispensed or days

the drug will be delivered.

If a Specialty Prescription Drug Product is provided

for less than or more than a 31-day supply, the Co-

payment and/or Co-insurance that applies will

reflect the number of days dispensed.

We designate certain Network Pharmacies to be

Preferred Specialty Network Pharmacies. We may

periodically change the Preferred Specialty

Network Pharmacy designation of a Network

Pharmacy. These changes may occur without prior

notice to you unless required by law. You may

determine whether a Network Pharmacy is a

Preferred Specialty Network Pharmacy by

contacting us at www.myuhc.com or by the

telephone number on your ID card.

Your Co-payment and/or Co-insurance is

determined by the PDL Management Committee's

tier placement of the Specialty Prescription Drug

Product. All Specialty Prescription Drug Products

on the Prescription Drug List are placed on Tier 1,

Tier 2, Tier 3, or Tier 4. Please contact us at

www.myuhc.com or the telephone number on your

ID card to find out tier placement.

Preferred Specialty Network Pharmacy

For a Tier 1 Specialty Prescription Drug Product:

$10 per Prescription Order or Refill.

For a Tier 1 Specialty Prescription Drug Product on

the List of Preventive Medications: $5 per

Prescription Order or Refill.

For a Tier 2 Specialty Prescription Drug Product:

$60 per Prescription Order or Refill.

For a Tier 2 Specialty Prescription Drug Product on

the List of Preventive Medications: $5 per

Prescription Order or Refill.

For a Tier 3 Specialty Prescription Drug Product:

$150 per Prescription Order or Refill.

For a Tier 3 Specialty Prescription Drug Product on

the List of Preventive Medications: $5 per

Prescription Order or Refill.

For a Tier 4 Specialty Prescription Drug Product:

$500 per Prescription Order or Refill.

For a Tier 4 Specialty Prescription Drug Product on

the List of Preventive Medications: $5 per

Prescription Order or Refill.

If you choose to obtain your Specialty Prescription

Non-Preferred Specialty Network Pharmacy

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The amounts you are required to pay as shown below in the Outpatient Prescription Drug

Schedule of Benefits are based on the Prescription Drug Charge for Network Benefits and the

Out-of-Network Reimbursement Rate for out-of-Network Benefits. For out-of-Network Benefits,

you are responsible for the difference between the Out-of-Network Reimbursement Rate and the

out-of-Network Pharmacy's Usual and Customary Charge.

Description and Supply Limits

What Is the Co-payment or Co-

insurance You Pay?

This May Include a Co-payment, Co-insurance

or Both

Drug Product from a Non-Preferred Specialty

Network Pharmacy, you will be required to pay 2

times the Preferred Specialty Network Pharmacy

Co-payment and/or 2 times the Preferred Specialty

Network Pharmacy Co-insurance (up to 50% of the

Prescription Drug Charge) based on the applicable

Tier.

Supply limits apply to Specialty Prescription Drug

Products obtained at a Preferred Specialty Network

Pharmacy, a Non-Preferred Specialty Network

Pharmacy, an out-of-Network Pharmacy, a mail

order Network Pharmacy or a Designated

Pharmacy.

You will be required to pay 2 times the Preferred

Specialty Network Pharmacy Co-payment and/or 2

times the Preferred Specialty Network Pharmacy

Co-insurance (up to 50% of the Prescription Drug

Charge) based on the applicable Tier.

Out-of-Network Pharmacy

For a Tier 1 Specialty Prescription Drug Product:

$10 per Prescription Order or Refill.

For a Tier 1 Specialty Prescription Drug Product on

the List of Preventive Medications: $5 per

Prescription Order or Refill.

For a Tier 2 Specialty Prescription Drug Product:

$60 per Prescription Order or Refill.

For a Tier 2 Specialty Prescription Drug Product on

the List of Preventive Medications: $5 per

Prescription Order or Refill.

For a Tier 3 Specialty Prescription Drug Product:

$150 per Prescription Order or Refill.

For a Tier 3 Specialty Prescription Drug Product on

the List of Preventive Medications: $5 per

Prescription Order or Refill.

For a Tier 4 Specialty Prescription Drug Product:

$500 per Prescription Order or Refill.

For a Tier 4 Specialty Prescription Drug Product on

the List of Preventive Medications: $5 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

Your Co-payment and/or Co-insurance is

determined by the PDL Management Committee's

tier placement of the Prescription Drug Product. All

Prescription Drug Products on the Prescription

Drug List are placed on Tier 1, Tier 2, Tier 3, or Tier

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The amounts you are required to pay as shown below in the Outpatient Prescription Drug

Schedule of Benefits are based on the Prescription Drug Charge for Network Benefits and the

Out-of-Network Reimbursement Rate for out-of-Network Benefits. For out-of-Network Benefits,

you are responsible for the difference between the Out-of-Network Reimbursement Rate and the

out-of-Network Pharmacy's Usual and Customary Charge.

Description and Supply Limits

What Is the Co-payment or Co-

insurance You Pay?

This May Include a Co-payment, Co-insurance

or Both

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 Co-payment and/or Co-insurance

for each cycle supplied. You may also

receive up to a 12-month cycle of the same

contraceptive for subsequent dispensing at

one time if you pay a Co-payment and/or Co-

insurance for each cycle supplied, when the

prescriber writes the script to fill a 12-month

fill.

Benefits for contraceptive supplies will be provided

without application of Deductibles, Co-payments,

Co-insurance or other cost-sharing requirement. If

the U.S. Food and Drug Administration (FDA) has

approved one or more therapeutic equivalent of a

contraceptive supply, at least one will be covered

without the application of Deductibles, Co-

payments, Co-insurance or other cost-sharing.

Benefits will be provided without application of

Deductible, Co-payments and/or Co-insurance for

at least one HIV prevention drug within each

method of administration.

When a Prescription Drug Product is packaged or

designed to deliver in a manner that provides more

than a consecutive 31-day supply, the Co-payment

and/or Co-insurance that applies will reflect the

number of days dispensed or days the drug will be

delivered.

4. Please contact us at www.myuhc.com or the

telephone number on your ID card to find out tier

status.

For a Tier 1 Prescription Drug Product: $10 per

Prescription Order or Refill.

For a Tier 1 Prescription Drug Product on the List of

Preventive Medications: $5 per Prescription Order

or Refill.

For a Tier 2 Prescription Drug Product: $60 per

Prescription Order or Refill.

For a Tier 2 Prescription Drug Product on the List of

Preventive Medications: $5 per Prescription Order

or Refill.

For a Tier 3 Prescription Drug Product: $150 per

Prescription Order or Refill.

For a Tier 3 Prescription Drug Product on the List of

Preventive Medications: $5 per Prescription Order

or Refill.

For a Tier 4 Prescription Drug Product: $300 per

Prescription Order or Refill.

For a Tier 4 Prescription Drug Product on the List of

Preventive Medications: $5 per Prescription Order

or Refill.

Prescription Drugs from a Retail Out-of-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

Your Co-payment and/or Co-insurance is

determined by the PDL Management Committee's

tier placement of the Prescription Drug Product. All

Prescription Drug Products on the Prescription

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200

The amounts you are required to pay as shown below in the Outpatient Prescription Drug

Schedule of Benefits are based on the Prescription Drug Charge for Network Benefits and the

Out-of-Network Reimbursement Rate for out-of-Network Benefits. For out-of-Network Benefits,

you are responsible for the difference between the Out-of-Network Reimbursement Rate and the

out-of-Network Pharmacy's Usual and Customary Charge.

Description and Supply Limits

What Is the Co-payment or Co-

insurance You Pay?

This May Include a Co-payment, Co-insurance

or Both

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 Co-payment and/or Co-insurance

for each cycle supplied. You may also

receive up to a 12-month cycle of the same

contraceptive for subsequent dispensing at

one time if you pay a Co-payment and/or Co-

insurance for each cycle supplied, when the

prescriber writes the script to fill a 12-month

fill.

Benefits will be provided without application of

Deductibles, Co-payments and/or Co-insurance for

at least one contraceptive supply within each

method of contraception.

Benefits will be provided without application of

Deductible, Co-payments and/or Co-insurance for

at least one HIV prevention drug within each

method of administration.

When a Prescription Drug Product is packaged or

designed to deliver in a manner that provides more

than a consecutive 31-day supply, the Co-payment

and/or Co-insurance that applies will reflect the

number of days dispensed or days the drug will be

delivered.

Drug List are placed on Tier 1, Tier 2, Tier 3, or Tier

4. Please contact us at www.myuhc.com or the

telephone number on your ID card to find out tier

status.

For a Tier 1 Prescription Drug Product: $10 per

Prescription Order or Refill.

For a Tier 1 Prescription Drug Product on the List of

Preventive Medications: $5 per Prescription Order

or Refill.

For a Tier 2 Prescription Drug Product: $60 per

Prescription Order or Refill.

For a Tier 2 Prescription Drug Product on the List of

Preventive Medications: $5 per Prescription Order

or Refill.

For a Tier 3 Prescription Drug Product: $150 per

Prescription Order or Refill.

For a Tier 3 Prescription Drug Product on the List of

Preventive Medications: $5 per Prescription Order

or Refill.

For a Tier 4 Prescription Drug Product: $300 per

Prescription Order or Refill.

For a Tier 4 Prescription Drug Product on the List of

Preventive Medications: $5 per Prescription Order

or Refill.

Prescription Drug Products from a Mail Order

Network Pharmacy or Preferred 90 Day Retail

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

Your Co-payment and/or Co-insurance is

determined by the PDL Management Committee's

tier placement of the Prescription Drug Product. All

Prescription Drug Products on the Prescription

Drug List are placed on Tier 1, Tier 2, Tier 3, or Tier

4. Please contact us at www.myuhc.com or the

SBN23.RX.NET-OON.I.2018.SG.ME

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The amounts you are required to pay as shown below in the Outpatient Prescription Drug

Schedule of Benefits are based on the Prescription Drug Charge for Network Benefits and the

Out-of-Network Reimbursement Rate for out-of-Network Benefits. For out-of-Network Benefits,

you are responsible for the difference between the Out-of-Network Reimbursement Rate and the

out-of-Network Pharmacy's Usual and Customary Charge.

Description and Supply Limits

What Is the Co-payment or Co-

insurance You Pay?

This May Include a Co-payment, Co-insurance

or Both

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 the first Prescription

Drug Product order and obtain 2 refills through a

retail pharmacy before using a mail order Network

Pharmacy.

To maximize your Benefit, ask your Physician to

write your Prescription Order or Refill for a 90-day

supply, with refills when appropriate. You will be

charged a Co-payment and/or Co-insurance based

on the day supply dispensed for any Prescription

Orders or Refills sent to the mail order Network

Pharmacy or Preferred 90 Day Retail Network

Pharmacy. Be sure your Physician writes your

Prescription Order or Refill for a 90-day supply, not

a 30-day supply with three refills.

For insulin Prescription Drug Products on any tier,

the total amount of deductibles, Co-payments, Co-

insurance or other cost sharing requirements shall

not exceed $35 per prescription up to a 30-day

supply; $70 per prescription up to a 60-day supply;

$105 per prescription up to a 90-day supply per

regardless of the amount of insulin needed to fill

your insulin prescriptions.

telephone number on your ID card to find out tier

status.

For up to a 31-day supply at a mail order Network

Pharmacy, you pay:

For a Tier 1 Prescription Drug Product: $10 per

Prescription Order or Refill.

For a Tier 1 Prescription Drug Product on the List of

Preventive Medications: $5 per Prescription Order

or Refill.

For a Tier 2 Prescription Drug Product: $60 per

Prescription Order or Refill.

For a Tier 2 Prescription Drug Product on the List of

Preventive Medications: $5 per Prescription Order

or Refill.

For a Tier 3 Prescription Drug Product: $150 per

Prescription Order or Refill.

For a Tier 3 Prescription Drug Product on the List of

Preventive Medications: $5 per Prescription Order

or Refill.

For a Tier 4 Prescription Drug Product: $300 per

Prescription Order or Refill.

For a Tier 4 Prescription Drug Product on the List of

Preventive Medications: $5 per Prescription Order

or Refill.

For up to a 60-day supply at a mail order Network

Pharmacy, you pay:

For a Tier 1 Prescription Drug Product: $20 per

Prescription Order or Refill.

For a Tier 1 Prescription Drug Product on the List of

Preventive Medications: $10 per Prescription Order

or Refill.

For a Tier 2 Prescription Drug Product: $120 per

Prescription Order or Refill.

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The amounts you are required to pay as shown below in the Outpatient Prescription Drug

Schedule of Benefits are based on the Prescription Drug Charge for Network Benefits and the

Out-of-Network Reimbursement Rate for out-of-Network Benefits. For out-of-Network Benefits,

you are responsible for the difference between the Out-of-Network Reimbursement Rate and the

out-of-Network Pharmacy's Usual and Customary Charge.

Description and Supply Limits

What Is the Co-payment or Co-

insurance You Pay?

This May Include a Co-payment, Co-insurance

or Both

For a Tier 2 Prescription Drug Product on the List of

Preventive Medications: $10 per Prescription Order

or Refill.

For a Tier 3 Prescription Drug Product: $300 per

Prescription Order or Refill.

For a Tier 3 Prescription Drug Product on the List of

Preventive Medications: $10 per Prescription Order

or Refill.

For a Tier 4 Prescription Drug Product: $600 per

Prescription Order or Refill.

For a Tier 4 Prescription Drug Product on the List of

Preventive Medications: $10 per Prescription Order

or Refill.

For up to a 90-day supply at a mail order Network

Pharmacy or Preferred 90 Day Retail Network

Pharmacy, you pay:

For a Tier 1 Prescription Drug Product: $25 per

Prescription Order or Refill.

For a Tier 1 Prescription Drug Product on the List of

Preventive Medications: $12.50 per Prescription

Order or Refill.

For a Tier 2 Prescription Drug Product: $150 per

Prescription Order or Refill.

For a Tier 2 Prescription Drug Product on the List of

Preventive Medications: $12.50 per Prescription

Order or Refill.

For a Tier 3 Prescription Drug Product: $375 per

Prescription Order or Refill.

For a Tier 3 Prescription Drug Product on the List of

Preventive Medications: $12.50 per Prescription

Order or Refill.

For a Tier 4 Prescription Drug Product: $750 per

Prescription Order or Refill.

For a Tier 4 Prescription Drug Product on the List of

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The amounts you are required to pay as shown below in the Outpatient Prescription Drug

Schedule of Benefits are based on the Prescription Drug Charge for Network Benefits and the

Out-of-Network Reimbursement Rate for out-of-Network Benefits. For out-of-Network Benefits,

you are responsible for the difference between the Out-of-Network Reimbursement Rate and the

out-of-Network Pharmacy's Usual and Customary Charge.

Description and Supply Limits

What Is the Co-payment or Co-

insurance You Pay?

This May Include a Co-payment, Co-insurance

or Both

Preventive Medications: $12.50 per Prescription

Order or Refill.