|
United Healthcare Choice Plus Plan
Option I
Choice Plus plan gives you the freedom to see any Physician or other
health care professional from our Network, including specialists,
without a referral. With this plan, you will receive the highest level
of benefits when you seek care from a network physician, facility or
other health care professional. In addition, you do not have to worry
about any claim forms or bills.
You also may choose to seek care outside the Network, without a
referral. However, you should know that care received from a non-network
physician, facility or other health care professional means a higher
deductible and Copayment. In addition, if you choose to seek care
outside the Network, UnitedHealthcare only pays a portion of those
charges and it is your responsibility to pay the remainder. This amount
you are required to pay, which could be significant, does not apply to
the Out-of-Pocket Maximum. We recommend that you ask the non-network
physician or health care professional about their billed charges before
you receive care.
Some of the Important Benefits of Your Plan
You have access to a Network of physicians, facilities and other
health care professionals, including specialists, without designating a
Primary Physician or obtaining a referral.
Benefits are available for office visits and hospital care, as well as
inpatient and outpatient surgery.
Care CoordinationSM services are available to help identify
and prevent delays in care for those who might need specialized help.
• Emergencies are covered anywhere in the world.
• Pap smears are covered.
• Prenatal care is covered.
• Routine check-ups are covered.
• Childhood immunizations are covered.
• Mammograms are covered.
• Vision and hearing screenings are covered.
Exclusions
Except as may be specifically provided in Section 1 of the
Certificate of Coverage (COC) or through a Rider to the Policy, the
following are not covered:
A. Alternative Treatments
Acupressure; hypnotism; rolfing; massage therapy; aroma therapy;
acupuncture; and other forms of Alternative Treatment.
B. Comfort or Convenience
Personal comfort or convenience items or services such as television;
telephone; barber or beauty service; guest service; supplies, equipment
and similar incidental services and supplies for personal comfort
including air conditioners, air purifiers and filters, batteries and
battery chargers, dehumidifiers and humidifiers; devices or computers to
assist in communication and speech.
C. Dental
Except as specifically described as covered in Section 1 of the COC
under the headings Dental Services - Accident Only and Dental Services -
Anesthesia and Hospital or Facility Charges, dental services are
excluded. There is no coverage for services provided for the prevention,
diagnosis, and treatment of the teeth, jawbones or gums (including
extraction, restoration, and replacement of teeth, medical or surgical
treatments of dental conditions, and services to improve dental clinical
outcomes). Dental implants and dental braces are excluded. Dental
x-rays, supplies and appliances and all associated expenses arising out
of such dental services (including hospitalizations and anesthesia) are
excluded, except as might otherwise be required for transplant
preparation, initiation of immunosuppressives, or the direct treatment
of acute traumatic injury, cancer, or cleft palate. Treatment for
congenitally missing, malpositioned, or super numerary teeth is
excluded, even if part of a Congenital Anomaly.
D. Drugs
Prescription drug products for outpatient use that are filled by a
prescription order or refill. Self- injectable medications (with the
exception of insulin). Non-injectable medications given in a Physician’s
office except as required in an Emergency. Over-the-counter drugs and
treatments.
E. Experimental, Investigational or Unproven Services
Experimental, Investigational or Unproven Services are excluded. The
fact that an Experimental, 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, Investigational or Unproven
in the treatment of that particular condition. This exclusion does not
apply to Coverage of any drug soley on the basis that the drug has been
prescribed for the treatment of a type of cancer for which the drug has
not been approved by the FDA, except as specifically described in
Section 2 of the COC.
F. Foot Care
Routine foot care (including the cutting or removal of corns and
calluses); nail trimming, cutting, or debriding; hygienic and preventive
maintenance foot care; treatment of flat feet or subluxation of the
foot; shoe orthotics.
G. Medical Supplies and Appliances
Devices used specifically as safety items or to affect performance
primarily in sports-related activities. Prescribed or non-prescribed
medical supplies and disposable supplies including but not limited to
elastic stockings, ace bandages, gauze and dressings, ostomy supplies,
(diabetic supplies are covered. Please note that if you have an
outpatient prescription drug rider that provides coverage for diabetic
medications and supplies, Benefits are available under the Rider and not
this medical plan). Orthotic appliances that straighten or re-shape a
body part (including some types of braces). Tubings and masks are not
covered except when used with Durable Medical Equipment as described in
Section 1 of the COC.
H. Mental Health/Substance Abuse
Services performed in connection with conditions not classified in the
current edition of the Diagnostic and Statistical Manual of the American
Psychiatric Association. Services that extend beyond the period
necessary for short-term evaluation, diagnosis, treatment, or crisis
intervention. Treatment of insomnia and other sleep disorders, dementia,
neurological disorders, and other disorders with a known physical basis.
Treatment of Mental Illnesses which will not substantially improve
beyond the current level of functioning, or for conditions not subject
to favorable modification or management according to generally accepted
standards of psychiatric care, as determined by the Mental
Health/Substance Abuse Designee, including, but not limited to, conduct
and impulse control disorders; personality disorder; and paraphilias.
Services utilizing methadone treatment as maintenance, L.A.A.M.
(1-Alpha-Acetyl-Methadol), Cyclazocine, or their equivalents. Treatment
provided in connection with or to comply with involuntary commitments,
police detentions and other similar arrangements. Residential treatment
services.
I. Nutrition
Megavitamin and nutrition based therapy; nutritional counseling for
either individuals or groups. Enteral feedings and other nutritional and
electrolyte supplements, including infant formula and donor breast milk.
J. Physical Appearance
Cosmetic Procedures including, but not limited to, pharmacological
regimens; nutritional procedures or treatments; salabrasion,
chemosurgery and other such skin abrasion procedures associated with the
removal of scars, tattoos, and/or which are performed as a treatment for
acne. Replacement of an existing breast implant is excluded if the
earlier breast implant was a Cosmetic Procedure. (Replacement of an
existing breast implant is considered reconstructive if the initial
breast implant followed mastectomy.)
Physical conditioning programs such as athletic training, bodybuilding,
exercise, fitness, flexibility, and diversion or general motivation.
Weight loss programs for medical and non-medical reasons. Wigs,
regardless of the reason for the hair loss.
K. Providers
Services performed by a provider with your same legal residence or who
is a family member by birth or marriage, including spouse, brother,
sister, parent or child. This includes any service the provider may
perform on himself or herself.
L. Reproduction
Health services and associated expenses for infertility treatments.
Surrogate parenting. The reversal of voluntary sterilization.
M. Services Provided Under Another Plan
Health services for which other coverage is required by federal, state
or local law to be purchased or provided through other arrangements,
including but not limited to coverage paid by workers’ compensation,
no-fault automobile insurance, or similar legislation. If coverage under
workers. compensation. Health services for treatment of military
service-related disabilities, when you are legally entitled to other
coverage and facilities are reasonably available to you. Health services
while on active military duty.
N. Transplants
Health services for organ or tissue transplants are excluded, except
those specified as covered in Section 1 of the COC. Any solid organ
transplant that is performed as a treatment for cancer. Health services
connected with the removal of an organ or tissue from you for purposes
of a transplant to another person. Health services for transplants
involving mechanical or animal organs.
Transplant services that are not performed at a Designated Facility. Any
multiple organ transplant not listed as a Covered Health Service in
Section 1 of the COC.
O. Travel
Health services provided in a foreign country, unless required as
Emergency Health Services. Travel or transportation expenses, even
though prescribed by a Physician. Some travel expenses related to
covered transplantation services may be reimbursed at our discretion.
Travel and living expenses are reimbursed if you receive transplant
services from a Designated Facility.
P. Vision and Hearing
Purchase cost of eye glasses, contact lenses, or hearing aids. Fitting
charge for hearing aids, eye glasses or contact lenses. Eye exercise
therapy. Surgery that is intended to allow you to see better without
glasses or other vision correction including radial keratotomy, laser,
and other refractive eye surgery.
Q. Other Exclusions
Health services and supplies that do not meet the definition of a
Covered Health Service - see definition in Section 10 of the COC:
• Physical, psychiatric or psychological examinations, testing,
vaccinations, immunizations or treatments otherwise covered under the
Policy, when such services are: (1) required solely for purposes of
career, education, sports or camp, travel, employment, insurance,
marriage or adoption; (2) relating to judicial or administrative
proceedings or orders; (3) conducted for purposes of medical research;
or (4) to obtain or maintain a license of any type.
• Health services received as a result of war or any act of war, whether
declared or undeclared, or caused during service in the armed forces of
any country.
• Health services received after the date your coverage under the Policy
ends, including health services for medical conditions arising prior to
the date your coverage under the Policy ends.
• Health services for which you have no legal responsibility to pay, or
for which a charge would not ordinarily be made in the absence of
coverage under the Policy
• Charges in excess of Eligible Expenses or in excess of any specified
limitation
• Orthognathic surgery or jaw alignment, except as a treatment for the
temporomandibular joint or obstructive sleep apnea
• Surgical treatment and non-surgical treatment of obesity (including
morbid obesity)
• Growth hormone therapy except as a Dependent child who requires growth
hormones to treat a Congenital Anomoly; sex transformation operations;
treatment of benign gynecosmastia (abnormal breast enlargement in
males); medical and surgical treatment of excessive sweating (hyperhidrosis);
medical and surgical treatment for snoring, except when provided as part
of treatment for documented obstructive sleep apnea. Oral appliances for
snoring. Custodial care; domiciliary care; private duty nursing; respite
care; rest cures
• Psychosurgery
• Speech therapy except as required for treatment of a speech impediment
or speech dysfunction that results from Injury, stroke or Congenital
Anomaly
This Summary of Benefits is intended only to highlight your benefits and
should not be relied upon to fully determine coverage. This plan may not
cover all your health care expenses. Please refer to the Certificate of
Coverage for a complete listing of services, limitations, exclusions and
a description of all the terms and conditions of coverage. If this
description conflicts in any way with the Certificate of Coverage, the
Certificate of Coverage prevails. Terms that are capitalized in the
Benefit Summary are defined in the Certificate of Coverage.
NOTE: There should also be a Customer service number
located on your I.D. card.
Monthly Rates - Option I
| Employee
(City pays $437.72) |
$30.00 |
| Employee
& Spouse |
$464.25 |
| Employee
& Children |
$394.03 |
| Family
|
$854.60 |
top
United Healthcare Choice Plus Plan
Option II
HSA Frequently Asked
Questions
HSA Letter to Physicians
• City Contribution to the High Deductible
plan (HSA)- $750.00
• If you participate in the HSA, you cannot
contribute to the FSA (Health Care Choice Flexible Spending Account)
• There are no pharmacy co-pays after you have met the
deductible since the deductible is the maximum out of pocket
With this HSA Choice Plus high-deductible
health plan coverage, you have the option to open a Health Savings Account (HSA).
An HSA is a financial account that you can use to accumulate tax-free funds to
pay for qualified health care expenses, as defined by the Internal Revenue
Service. The account acts like a regular checking account with a debit card and
accrues interest. All money in the account is owned by you and is fully vested
as soon as it is deposited. Funds can accumulate over time and the account is
portable among employers. If you use the funds for qualified health care
expenses, you will pay no taxes. If you use the money for other expenses, you
will pay a tax and a penalty fee.
Under the HSA Choice Plus high-deductible medical plan, your
annual deductible and out of pocket maximum includes both medical expenses and
pharmacy expenses. All expenses are your responsibility until the deductible is
reached. HSA Choice Plus plan gives you the freedom to see any Physician or
other health care professional from our Network, including specialists, without
a referral. With this plan, you will receive the highest level of benefits when
you seek care from a network physician, facility or other health care
professional. In addition, you do not have to worry about any claim forms or
bills.
You also may choose to seek care outside the Network, without a
referral. However, you should know that care received from a non-network
physician, facility or other health care professional means a higher deductible
and Copayment. In addition, if you choose to seek care outside the Network,
UnitedHealthcare only pays a portion of those charges and it is your
responsibility to pay the remainder. This amount you are required to pay, which
could be significant, does not apply to the Out-of-Pocket Maximum. We recommend
that you ask the non-network physician or health care professional about their
billed charges before you receive care.
Some of the Important Benefits of Your Plan:
You have access to a Network of physicians,
facilities and other health care professionals, including specialists, without
designating a Primary Physician or obtaining a referral. Benefits are available
for office visits and hospital care, as well as inpatient and outpatient
surgery.
Care CoordinationSM services are available to help
identify and prevent delays in care for those who might need specialized help.
Emergencies are covered anywhere in the world. Pap smears are covered. Prenatal
care is covered. Routine check-ups are covered. Childhood immunizations are
covered. Mammograms are covered. Vision and hearing screenings are covered.
|
Types of Coverage |
Network Benefits / Copayment Amounts |
Non-Network Benefits / Copayment Amounts
|
|
This Benefit Summary is intended only to highlight
your Benefits and should not be relied upon to fully determine
coverage. This benefit plan may not cover all of your health care
expenses. More complete descriptions of Benefits and the terms under
which they are provided are contained in the Certificate of Coverage
that you will receive upon enrolling in the Plan.
If this Benefit Summary conflicts in any way with
the Policy issued to your employer, the Policy shall prevail. Terms
that are capitalized in the Benefit Summary are defined in the
Certificate of Coverage.
Where Benefits are subject to day, visit and/or
dollar limits, such limits apply to the combined use of Benefits
whether in-Network or out-of-Network, except where mandated by state
law.
Network Benefits are payable for Covered Health
Services provided by or under the direction of your Network
physician.
*Prior Notification is required for certain
services. |
Combined Medical and Drug Annual Deductible: For
single coverage, the Annual Deductible is $1,100 per Covered Person
per calendar year. For family coverage, the Annual Deductible is
$2,200 per calendar year for all Covered Persons in a family. No one
in the family is eligible for benefits until the family deductible
is satisfied.
Combined Medical and Drug Out-of-Pocket Maximum: For
single coverage, the Out-of-Pocket Maximum is $1,100 per Covered
Person per calendar year. For family coverage, the Out-of-Pocket
Maximum is $2,200 per calendar year for all Covered Persons in a
family. The Out-of-Pocket Maximum does include the Annual
Deductible.
Maximum Policy Benefit: No Maximum Policy Benefit.
|
Combined Medical and Drug Annual Deductible: For
single coverage, the Annual Deductible is $1,650 per Covered Person
per calendar year. For family coverage, the Annual Deductible is
$3,300 per calendar year for all Covered Persons in a family. No one
in the family is eligible for benefits until the family deductible
is satisfied.
Combined Medical and Drug Out-of-Pocket Maximum: For
single coverage, the Out-of-Pocket Maximum is $2,200 per Covered
Person per calendar year. For family coverage, the Out-of-Pocket
Maximum is $4,400 per calendar year for all Covered Persons in a
family. The Out-of-Pocket Maximum does include the Annual
Deductible.
Maximum Policy Benefit: $1,000,000 per Covered
Person. |
|
1. Ambulance Services - Emergency only
|
Ground Transportation: 0% of
Eligible Expenses
Air Transportation: 0% of
Eligible Expenses |
Same as Network Benefit
|
|
2. Dental Services - Accident only
|
*0% of Eligible Expenses
*Prior notification is required
before follow-up treatment begins. |
*Same as Network Benefit
*Prior notification is required
before follow-up treatment begins. |
|
3. Durable Medical Equipment Network and Non-Network
Benefits for Durable Medical Equipment are limited to $2,500 per
calendar year.
|
0% of Eligible Expenses
|
*20% of Eligible Expenses
*Prior notification is required
when the cost is more than $1,000. |
|
Types of Coverage
|
Network Benefits / Copayment Amounts
|
Non-Network Benefits / Copayment Amounts
|
|
4. Emergency Health Services
|
0% of Eligible Expenses
|
Same as Network Benefit
*Notification is required if
results in an Inpatient Stay. |
|
5. Eye Examinations
Refractive eye examinations are
limited to one every other calendar year from a Network Provider.
|
0% of Eligible Expenses
|
20% of Eligible Expenses
Eye Examinations for refractive
errors are not covered. |
|
6. Home Health Care
Network and Non-Network Benefits
are limited to 60 visits for skilled care services per calendar
year. |
0% of Eligible Expenses
|
*20% of Eligible Expenses
|
|
7. Hospice Care
Network and Non-Network Benefits
are limited to 360 days during the entire period of time a Covered
Person is covered under the Policy. |
0% of Eligible Expenses
|
*20% of Eligible Expenses
|
|
8. Hospital - Inpatient Stay
|
0% of Eligible Expenses
|
*20% of Eligible Expenses
|
|
9. Injections Received in a Physician's Office
|
0% per injection
|
20% per injection
|
|
10. Maternity Services
|
Same as 8, 11, 12 and 13
|
Same as 8, 11, 12 and 13
*Notification is required if
Inpatient Stay exceeds 48 hours following a normal vaginal delivery
or 96 hours following a cesarean section delivery.
|
|
11. Outpatient Surgery, Diagnostic and Therapeutic
Services
Outpatient Surgery
Outpatient Diagnostic Services
Outpatient Diagnostic/Therapeutic Services - CT
Scans, Pet Scans, MRI and Nuclear Medicine
Outpatient Therapeutic Treatments |
0% of Eligible Expenses
For preventive diagnostic
services: No Copayment For preventive mammography testing: No
Copayment
For sickness and injury related
diagnostic services: 0% of Eligible Expenses
0% of Eligible Expenses
0% of Eligible Expenses |
20% of Eligible Expenses
No Benefits for preventive care, except for state
mandates.
20% of Eligible Expenses
20% of Eligible Expenses
20% of Eligible Expenses |
|
Types of Coverage
|
Network Benefits / Copayment Amounts
|
Non-Network Benefits / Copayment Amounts
|
|
12. Physician’s Office Services
|
Preventive medical care: No
Copayment
Sickness & Injury: 0% of Eligible
Expenses |
No Benefits for preventive care,
except for state
mandates. 20% of Eligible
Expenses |
|
13. Professional Fees for Surgical and Medical
Services
|
0% of Eligible Expenses
|
20% of Eligible Expenses
|
|
14. Prosthetic Devices
Network and Non-Network Benefits
for prosthetic devices are limited to $2,500 per calendar year. |
0% of Eligible Expenses
|
20% of Eligible Expenses
|
|
15. Reconstructive Procedures
|
Same as 8, 11, 12, 13 and 14
|
*Same as 8, 11, 12, 13 and 14
|
|
16. Rehabilitation Services
-Outpatient Therapy
Network and Non-Network Benefits
are limited as follows: 20 visits of physical therapy; 20 visits of
occupational therapy; 20 visits of speech therapy; 20
visits of pulmonary
rehabilitation; and 36 visits of cardiac rehabilitation per calendar
year. |
0% of Eligible Expenses
|
20% of Eligible Expenses
|
|
17. Skilled Nursing
Facility/Inpatient Rehabilitation Facility Services
Network and Non-Network Benefits
are limited to 60 days per calendar year. |
0% of Eligible Expenses
|
*20% of Eligible Expenses
|
|
18. Transplantation Services
|
*0% of Eligible Expenses
|
*20% of Eligible Expenses Benefits are limited to
$30,000 per transplant.
|
|
19. Urgent Care Center Services
|
0% of Eligible Expenses
|
20% of Eligible Expenses
|
|
Additional Benefits
|
|
|
|
Dental - Anesthesia and Hospital
or Facility Charges
Benefits are limited for children
under 9 and persons with either serious mental/physical conditions
or significant behavior problems. |
*Same as 8, 11, 12 and 13
|
*Same as 8, 11, 12 and 13
|
|
Diabetes Services
|
0% of Eligible Expenses
|
20% of Eligible Expenses
|
|
Types of Coverage
|
Network Benefits / Copayment Amounts
|
Non-Network Benefits / Copayment Amounts
|
|
Mental Health and Substance Abuse
Services - Outpatient
Must receive prior authorization
through the Mental Health/Substance Abuse Designee. Network and
Non-Network Benefits for Mental Health Services are limited to 20
visits per calendar year. Network and Non-Network Benefits for
inpatient or outpatient Substance Abuse Services are limited to
$8,000 per calendar year. |
0% of Eligible Expenses
|
20% of Eligible Expenses
|
|
Mental Health and Substance Abuse
Services - Inpatient and Intermediate
Must receive prior authorization
through the Mental Health/Substance Abuse Designee. Network and
Non-Network Benefits for Mental Health Services are limited to 30
days per calendar year. Network and Non-Network Benefits for
inpatient or outpatient Substance Abuse Services are limited to
$8,000 per calendar year. |
0% of Eligible Expenses
|
20% of Eligible Expenses
|
|
Spinal Treatment
Benefits include diagnosis and
related services and are limited to one visit and treatment per day.
Network and Non-Network Benefits are limited to 24 visits per
calendar year. |
0% of Eligible Expenses
|
20% of Eligible Expenses
|
|
Temporomandibular Jaw Joint Disorder
|
Same as 8, 11, 12, 13 and 14
|
Same as 8, 11, 12, 13 and 14
|
Exclusions
Except as may be specifically provided in
Section 1 of the Certificate of Coverage (COC) or through a Rider to the Policy,
the following are not covered:
A. Alternative Treatments
Acupressure; hypnotism; rolfing; massage
therapy; aromatherapy; acupuncture; and other forms of alternative treatment.
B. Comfort or Convenience
Personal comfort or convenience items or
services such as television; telephone; barber or beauty service; guest service;
supplies, equipment and similar incidental services and supplies for personal
comfort including air conditioners, air purifiers and filters, batteries and
battery chargers,dehumidifiers and humidifiers; devices or computers to assist
in communication and speech.
C. Dental
Except as specifically described as covered
in Section 1 of the COC under the headings Dental Services -Accident Only and
Dental Services - Anesthesia and Hospital or Facility Charges, dental services
are excluded. There is no coverage for services provided for the prevention,
diagnosis, and treatment of the teeth, jawbones or gums (including extraction,
restoration, and replacement of teeth,
medical or surgical treatments of dental
conditions, and services to improve dental clinical outcomes).
Dental implants and dental braces are
excluded. Dental x-rays, supplies and appliances and all associated expenses
arising out of such dental services (including hospitalizations and anesthions
and anesthesia) are excluded, except as might otherwise be required for
transplant preparation, initiation of immunosuppressives, or the direct
treatment of acute traumatic Injury, cancer, or cleft palate.
Treatment for congenitally missing,
malpositioned, or super numerary teeth is excluded, even if part of a Congenital
Anomaly.
D. Drugs
Prescription drug products for outpatient use
that are filled by a prescription order or refill. Selfinjectable medications
(with the exception of insulin). Please note that if you have an outpatient
prescription drug rider that provides coverage for diabetic medications,
Benefits are available under the Rider and not this medical plan. Non-injectable
medications given in a Physician’s office except as required in an Emergency.
Over the counter drugs and treatments.
E. Experimental, Investigational or Unproven
Services
Experimental, Investigational or Unproven
Services are excluded. The fact that an Experimental, 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, Investigational or Unproven in
the treatment of that particular condition. This exclusion does not apply to
Coverage of any drug soley on the basis that the drug has been prescribed for
the treatment of a type of cancer for which the drug has not been approved by
the FDA, except as specifically described in Section 2 of the COC.
F. Foot Care
Routine foot care (including the cutting or
removal of corns and calluses); nail trimming, cutting, or debriding; hygienic
and preventive maintenance foot care; treatment of flat feet or subluxation of
the foot; shoe orthotics.
G. Medical Supplies and Appliances
Devices used specifically as safety items or
to affect performance primarily in sports-related activities. Prescribed or
non-prescribed medical supplies and disposable supplies including but not
limited to elastic stockings, ace bandages, gauze and dressings, ostomy
supplies, (diabetic supplies are covered.
Please note that if you have an outpatient
prescription drug rider that provides coverage for diabetic medications and
supplies, Benefits are available under the Rider and not this medical plan).
Orthotic appliances that straighten or re-shape a body part (including cranial
banding and some types of braces). Tubings and masks are not covered except when
used with Durable Medical Equipment as
described in Section 1 of the COC.
H. Mental Health/Substance Abuse
Services performed in connection with
conditions not classified in the current edition of the Diagnostic and
Statistical Manual of the American Psychiatric Association. Services that extend
beyond the period necessary for short-term evaluation, diagnosis, treatment, or
crisis intervention.
Mental Health treatment of insomnia and other sleep disorders,
neurological disorders, and other disorders with a known physical basis.
Treatment of conduct and impulse control disorders, personality
disorders, paraphilias and other Mental Illnesses that will not substantially
improve beyond the current level of functioning, or that are not subject to
favorable modification or management according to prevailing national standards
of clinical practice, as reasonably determined by the Mental Health/Substance
Abuse Designee.
Services utilizing methadone treatment as
maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol), Cyclazocine, or their
equivalents. Treatment provided in connection with or to comply with involuntary
commitments, police detentions and other similar arrangements, unless authorized
by the Mental Health/Substance Abuse Designee. Residential treatment services.
Services or supplies that in
the reasonable judgment of the Mental
Health/Substance Abuse Designee are not, for example, consistent with certain
national standards or professional research further described in Section 2 of
the COC.
I. Nutrition
Megavitamin and nutrition based therapy;
nutritional counseling for either individuals or groups. Enteral feedings and
other nutritional and electrolyte supplements, including infant formula and
donor breast milk.
J. Physical Appearance
Cosmetic Procedures including, but not
limited to, pharmacological regimens; nutritional procedures or treatments;
salabrasion, chemosurgery and other such skin abrasion procedures associated
with the removal of scars, tattoos, and/or
which are performed as a treatment for acne.
Replacement of an existing breast implant is excluded if the earlier breast
implant was a Cosmetic Procedure.
(Replacement of an existing breast implant is
considered reconstructive if the initial breast implant followed mastectomy.)
Physical conditioning programs such as athletic training, bodybuilding,
exercise, fitness, flexibility, and diversion or general motivation. Weight loss
programs for medical and non-medical reasons. Wigs, regardless of the reason for
the hair loss.
K. Providers
Services performed by a provider with your
same legal residence or who is a family member by birth or marriage, including
spouse, brother, sister, parent or child. This includes any service the provider
may perform on himself or herself. Services provided at a free-standing or
Hospital-based diagnostic facility without an order written by a Physician or
other provider as further described in Section 2 of the COC (this exclusion does
not apply to mammography testing).
L. Reproduction
Health services and associated expenses for
infertility treatments. Surrogate parenting. The reversal of voluntary
sterilization.
M. Services Provided under Another Plan
Health services for which other coverage is
required by federal, state or local law to be purchased or provided through
other arrangements, including but not limited to coverage required by workers’
compensation, no-fault automobile insurance, or similar legislation. If coverage
under workers’ compensation or similar legislation is optional because you could
elect it, or could have it elected for
you, Benefits will not be paid for any
Injury, Mental Illness or Sickness that would have been covered under workers’
compensation or similar legislation had that coverage been elected. Health
services for treatment of military service-related disabilities, when you are
legally entitled to other coverage and facilities are reasonably available to
you. Health services while on active military duty.
N. Transplants
Health services for organ or tissue
transplants are excluded, except those specified as covered in Section 1 of the
COC. Any solid organ transplant that is performed as a treatment for cancer.
Health services connected with the removal of an organ or tissue from you for
purposes of a transplant to another person. Health services for transplants
involving mechanical or animal organs. Any multiple organ transplant not listed
as a Covered Health Service in Section 1 of the COC.
O. Travel
Health services provided in a foreign
country, unless required as Emergency Health Services. Travel or transportation
expenses, even though prescribed by a Physician. Some travel expenses related to
covered transplantation services may be reimbursed at our discretion.
P. Vision and Hearing
Purchase cost of eye glasses, contact lenses,
or hearing aids. Fitting charge for hearing aids, eyeglasses or contact lenses.
Eye exercise therapy. Surgery that
is intended to allow you to see better
without glasses or other vision correction including radial keratotomy, laser,
and other refractive eye surgery.
Q. Other Exclusions
Health services and supplies that do not meet
the definition of a Covered Health Service - see definition in Section 10 of the
COC.
Physical, psychiatric or psychological examinations, testing,
vaccinations, immunizations or treatments otherwise covered under the Policy,
when such services are: (1) required solely for purposes of career, education,
sports or camp, travel, employment, insurance, marriage or adoption; (2)
relating to judicial or administrative proceedings or orders; (3) conducted for
purposes of medical research; or (4) to obtain or maintain a license of any
type.
Health services received as a result of war or any act of war,
whether declared or undeclared or caused during service in the armed forces of
any country.
Health services received after the date your coverage under the
Policy ends, including health services for medical conditions arising prior to
the date your coverage under the Policy ends.
Health services for which you have no legal responsibility to
pay, or for which a charge would not ordinarily be made in the absence of
coverage under the Policy.
Charges in excess of Eligible Expenses or in excess of any
specified limitation.
Orthognathic surgery or jaw alignment, except as treatment for
tempormandibular joint or obstructive sleep apnea.
Surgical treatment and non-surgical treatment of obesity
(including morbid obesity).
Growth hormone therapy, except as a Dependant
child who requires growth hormones to treat a Congenital Anomaly; sex
transformation operations; treatment of benign gynecomastia (abnormal breast
enlargement in males); medical and surgical treatment of excessive sweating (hyperhidrosis);
medical and surgical treatment for snoring, except when provided as part of
treatment for documented
obstructive sleep apnea. Oral appliances for
snoring. Custodial care; domiciliary care; private duty nursing; respite care;
rest cures.
Psychosurgery. Speech therapy except as required for treatment
of a speech impediment or speech dysfunction that results from Injury, stroke or
Congenital Anomaly.
This summary of Benefits is intended only to
highlight your Benefits and should not be relied upon to fully determine
coverage. This plan may not cover all your health care expenses. Please refer to
the Certificate of Coverage for a complete listing of services, limitations,
exclusions and a description of all the terms and conditions of coverage. If
this description conflicts in any way with the Certificate of Coverage, the
Certificate of Coverage prevails. Terms that are capitalized in the Benefit
Summary are defined in the Certificate of Coverage.
04I_BS_HSAChcPls NCLGFM3704 DDA 430-3540_1105
For customer service questions and claims,
please call United Healthcare Services: 800-259-1605.
For banking related questions on your
account, please call Exante Bank at
800-791-9361.
Monthly Rates - Option II
| Employee
(City pays $425.47) |
$30.00 |
| Employee
& Spouse |
$452.88 |
| Employee
& Children |
$384.51 |
| Family
|
$833.02 |
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United Healthcare Pharmacy Plan
UnitedHealthcare’s pharmacy management program
provides clinical pharmacy services that promote choice, accessibility
and value. The program offers a broad network of pharmacies (more than
50,000 nationwide) to provide convenient access to medications.
While most pharmacies participate in our network, you should check
first. Call your pharmacist or visit our online pharmacy service at
www.myuhc.com. The online service offers you home delivery of
prescriptions, ability to view personal benefit coverage, access health
and well being information, and even location of network retail
neighborhood pharmacies by zip code.
Copayment per Prescription
Order or Refill
For a single Copayment, you may receive a Prescription Drug
Product up to the stated supply limit. Some products are subject to
additional supply limits. You are responsible for paying the lower of
the applicable Copayment or the retail Network Pharmacy’s Usual and
Customary Charge, or the lower of the applicable Copayment or the mail
order Pharmacy’s Prescription Drug Cost.
Also note that some Prescription Drug Products require that you notify
us in advance to determine whether the Prescription Drug Product meets
the definition of a Covered Health Service and is not Experimental,
Investigational or Unproven.
|
|
Tier 1
Refer to the United
Healthcare Pharmacy Management Plan
|
Tier 2
Refer to
the United Healthcare Pharmacy Management Plan
|
Tier 3
Refer to
the United Healthcare Pharmacy Management Plan
|
|
Retail Network Pharmacy
For up to a
31 day supply
|
$10
|
$20
|
$40 |
|
Mail Service Network
Pharmacy
For up to a
90 day supply
|
$25
|
$50
|
$100 |
|
Retail
Non-Network Pharmacy
For up to a 31 day supply |
$10
|
$20
|
$40 |
*Our Preferred Drug List includes those drugs
available to you at the most affordable cost. It is one of the best ways
to maximize your prescription drug benefits. The drug list, developed by
physicians and pharmacists on our national Pharmacy and Therapeutics
committee, includes a wide selection of generic and brand name
prescription medications commonly prescribed by physicians. The
Preferred Drug List is updated throughout the year. The most current
version is available at our online pharmacy at www.myuhc.com.
Other Important Cost Sharing
Information
NOTE: If you purchase Prescription Drug Product from a
Non-Network pharmacy, you are responsible for any difference between
what the Non-Network pharmacy charges and the amount we would have paid
for the same Prescription Drug Product dispensed by a Network pharmacy.
Annual Drug Deductible FOR
Network and Non-Network Pharmacies
$100 per Covered Person per calendar year, not to exceed $300
for all covered persons in a family.
Exclusions
Exclusions from coverage listed in the Certificate apply also
to this Rider. In addition, the following exclusions apply:
• Outpatient Prescription Drug Products obtained from a non-Network
Pharmacy.
• Coverage for Prescription Drug Products for the amount dispensed (days
supply or quantity limit) which exceeds the supply limit.
• Drugs which are prescribed, dispensed or intended for use while you
are an inpatient in a Hospital, Skilled Nursing Facility, or Alternate
Facility.
• Experimental, Investigational or Unproven Services and medications;
medications used for experimental indications and/or dosage regimens
determined by us to be experimental.
• This exclusion does not apply to any drug solely on the basis that the
drug has been prescribed for the treatment of a type of cancer for which
the drug has not yet been approved by the FDA as specifically described
in Section 2 of the COC.
• Prescription Drug Products furnished by the local, state or federal
government. Any Prescription Drug Product to the extent payment or
benefits are provided or available from the local, state or federal
government (for example, Medicare) whether or not payment or benefits
are received, except as otherwise provided by law.
• Prescription Drug Products for any condition, Injury, Sickness or
mental illness arising out of, or in the course of, employment for which
benefits are available under any workers’ compensation law or other
similar laws, whether or not a claim for such benefits is made or
payment or benefits are received.
• Any product dispensed for the purpose of appetite suppression and
other weight loss products.
• Compounded drugs that do not contain at
least one ingredient that requires a Prescription Order or Refill.
• Drugs available over-the-counter that do not require a Prescription
Order or Refill by federal or state law before being dispensed. Any drug
that is therapeutically equivalent to an over-the-counter drug.
• A specialty medication Prescription Drug Product (such as
immunizations and allergy serum) which, due to its characteristics as
determined by us, must typically be administered or supervised by a
qualified provider or licensed/certified health professional in an
outpatient setting. This does not apply to Depo Provera and other
injectable drugs used for contraception.
• Durable Medical Equipment. Prescribed and non-prescribed outpatient
supplies, other than the diabetic supplies and inhaler spacers
specifically stated as covered.
• Prescription Drug Products when prescribed to treat infertility.
• Replacement Prescription Drug Products resulting from a lost, stolen,
broken or destroyed Prescription Order or Refill.
• General and Injectable Vitamins, except the following which require a
Prescription Order or Refill: prenatal vitamins, vitamins with fluoride,
and single entity vitamins.
• Prescription Drug Products for smoking cessation.
• Unit dose packaging of Prescription Drug Products.
• Medications used for cosmetic purposes.
• New Prescription Drug Products and/or new dosage forms until they are
reviewed and approved by our Pharmacy and Therapeutics Committee.
• Prescription Drug Products, including new Prescription Drug Products,
or new dosage form that are determined to not be a Covered Health
Service.
This Summary of Benefits is intended only to highlight your benefits for
outpatient Prescription Drug Products and should not be relied upon to
determine coverage. Your plan may not cover all your outpatient
prescription drug expenses. Please refer to your Outpatient Prescription
Drug Rider and the Certificate of Coverage for a complete listing of
services, limitations, exclusions and a description of all the terms and
conditions of coverage. If this description conflicts in any way with
the Outpatient Prescription Drug Rider or the Certificate of Coverage,
the Outpatient Prescription Drug Rider and Certificate of Coverage
prevail. Capitalized terms in the Benefit Summary are defined in the
Outpatient Prescription Drug Rider and/or Certificate of Coverage.
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