Coverage under this plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

See www.opm.gov/healthcare-insurance for enrollment information as well as:

• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies who participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, give you other plans' brochures and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
• What happens when your enrollment ends
• When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address updates and questions about your benefit coverage.

Self Only coverage is only for you the enrollee. Self Plus One coverage is for the enrollee and one eligible family member. Self and Family coverage is for the enrollee, and one or more eligible family members.  Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31-days before to 60-days after that event. The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

Contact your employing or retirement office if you want to change from Self Only to Self Plus One or Self and Family. If you have a Self and Family enrollment, you may contact us to add a family member.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26. We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26^th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26.

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events. If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by valid common-law marriage from a state that recognizes common-law marriages) and children as described in the chart below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

OPM implements the Federal Employees Health Benefits Children’s Equity Act of 2000.  This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children.  If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM. 
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or

If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM. 

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children. 

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Contact your employing office for further information.

The benefits in this brochure are effective on January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2025 benefits of your prior plan or option.  If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option.  However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2024 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage, (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid.  You may be billed for services received directly from your provider.  You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums.  It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment, or
• You are a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC) or a conversion policy (a non-FEHB individual policy).

If you are an enrollee and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment. You must contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof. In order to change enrollment type, you must contact your employing or retirement office. A change will not automatically be made.

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get information about your coverage choices. You can also visit OPM’s Web site, https://www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment. 

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, or if you are a covered child and you turn 26.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance . It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll.  Finally, if you qualify for coverage under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30-days of losing FEHB Program coverage.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must contact us in writing within 31- days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing within 31-days after you are no longer eligible for coverage. 

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace guaranteed issue in your state. For assistance in finding coverage, please contact us at 877-835-9861.

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov.  This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30-days after the effective date of your enrollment, or if you need replacement cards, call us at 1-877-835-9861, or write to us at United Healthcare Insurance Company  Inc., Federal Employees Health Benefits (FEHB) Program, at P.O. Box 30432, Salt Lake City, UT 84130-0432. You may also print temporary cards and request replacement cards through our web site www.myuhc.com.

You get care from “Plan providers” and “Plan facilities”. You will only pay copayments, and/or coinsurance. If you use our Open Access program you can receive covered services from a participating provider without a required referral from your primary care provider or by another participating provider in the network.

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. Services by Plan Providers are covered when acting within the scope of their license or certification under applicable state law. We credential Plan providers according to national standards.

Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area.

We list Plan providers in the provider directory, which we update periodically. The provider search tool is available on our Web sites at www.myuhc.com and www.uhcfeds.com.

This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.

This plan provides Care Coordinators for complex conditions and can be reached 877-835-9761 for assistance.

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The provider search tool is available from our Web sites www.myuhc.com and www.uhcfeds.com.

FEHB Carriers must have clauses in their in-network (participating) provider agreements.  These clauses provide that, for a service that is a  covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount.  If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract.

You do not need to select a primary care provider and you do not need to get written referrals to see a contracted specialist for medical services. The provider must be participating for services to be covered. You need to call Customer Service at 1-877-835-9861 to obtain authorization for some services. Prior authorization for Prosthetic devices or durable medical equipment is required when the item costs more than $1,000 or for some therapies, radiology and procedures.  Please refer to prior approval in this section for more information or call customer service at 1-877-835-9861. The Plan will provide benefits for covered services only when the services are medically necessary to prevent, diagnose or treat your illness or condition.

Your primary care provider (PCP) can be a family practitioner, internist, or pediatrician. Your primary care provider (PCP) will provide most of your healthcare

You do not need to have a referral to see a participating specialist.  If you need the care of a specialist, you may select a specialist from our provider directory, or call your PCP who will assist you in locating an appropriate participating provider. 

Here are some other things you should know about specialty care:

• If you are seeing a specialist when you enroll in our Plan, check with the specialist to verify that the specialist is participating with the Plan. If the specialist is contracted with the Plan, you may continue to see the provider. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
• If you are seeing a specialist and your specialist leaves the Plan, call your primary care provider, who can assist you in locating another specialist.

If you have a chronic and disabling condition and lose access to your specialist because we:

• terminate our contract with your specialist for other than cause;
• drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or
• reduce our service area and you enroll in another FEHB plan,

you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Your Plan primary care provider or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

We pay for covered services from the effective date of your enrollment.  However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-877-835-9861 If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 92^nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

Since your primary care provider arranges most referrals to specialists and inpatient hospitalization, the pre-service claim approval process only applies to care shown under Other services.

Precertification is the process by which - prior to your inpatient hospital admission - we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition.

You do not need to have a referral to see a participating specialist. For certain services, however, you or your physician must obtain prior approval from us. We call this review and approval process prior notification. You or your physician must obtain prior notification for some services such as, but not limited to the following:

• Applied Behavioral Analysis (ABA)
• Air Ambulance (non-emergent)
• Capsule endoscopy
• Clinical trials
• Congenital anomaly repair
• CT Scans (Computed tomography)
• Dialysis
• Discectomy/fusion
• Durable medical equipment over $1,000 
• Electro-convulsive therapy 
• Gender Affirming Surgical procedures
• Growth hormone therapy (GHT)
• Hysterectomy
• Iatrogenic Infertility Services
• Infertility Services
• Inpatient Hospitalization
• Intensive Outpatient treatments
• Joint replacement 
• Magnetic resonance angiogram (MRA) 
• Magnetic resonance imaging (MRI) 
• Morbid obesity surgery 
• Nuclear medicine studies including nuclear cardiology. 
• Orthopedic and prosthetic devices over $1,000
• Partial hospitalization
• PET scans
• Psychological, neurophysiological and extended developmental testing
• Reconstructive surgery
• Rhinoplasty/septo-rhinoplasty
• Sleep apnea - surgery and appliance (with sleep studies); sleep studies (polysomnograms) - attended
• Substance use disorder treatments
• Vein Ablation
• Virtual Colonoscopy
• Transplants

First, your physician, your hospital, you, or your representative, must call us at 1-877-835-9861 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

• enrollee’s name and Plan identification number;
• patient’s name, birth date, identification number and phone number;
• reason for hospitalization, proposed treatment, or surgery;
• name and phone number of admitting physician;
• name of hospital or facility; and
• number of planned days of confinement.

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15-days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15-days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60-days from the receipt of the notice to provide the information.

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours.  If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide  the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 1-877-835-9861. You may also call OPM’s FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 1-877-835-9861. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

A concurrent care claim involves care provided over a period of time or over a number of treatments.  We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends.  If we believe a reduction or termination is warranted we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect. 

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must phone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital

Your physician, your hospital, you or your representative, must call us at 1-877-835-9861 prior to admission. 

Further, if your baby stays after you are discharged, then your physician or the hospital must contact us for pre-certification of additional days for your baby.

Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, the newborn is considered a patient in his or her own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call 877-835-9861

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to

1. Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or

2. Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.

3. Write to you and maintain our denial.

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

Subject to a request for additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request.  We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

Example: When you see your primary care provider you pay a copayment of $25 per office visit and when you go in the hospital, you pay $150 per day up to a maximum of  $750 per admission.

Coinsurance is the percentage of our allowance that you must pay for your care. 

You should also see section Important Notice About Surprise Billing - Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

After your out-of-pocket expenses, including any applicable deductibles, copayments and coinsurance total $5,000 for Self Only, or $10,000 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services.

The maximum annual limitation on cost sharing listed under Self Only of $5,000 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

Example Scenario:  Your plan has a $5,000 Self Only maximum out-of-pocket limit and a $10,000 Self Plus One or Self and Family maximum out-of-pocket limit. If you or one of your eligible family members has out-of-pocket qualified medical expenses of $5,000 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan.  With a Self and Family enrollment out-of-pocket maximum of $10,000, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $10,000 for the calendar year before their qualified medical expenses will begin to be covered in full. 

However, copayments and coinsurance, if applicable for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for these services:

• Copayments or coinsurance for chiropractic services 
• Expenses for services and supplies that exceed the stated maximum dollar or day limit
• Expenses from utilizing out-of-network providers

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services.

A surprise bill is an unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services.

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from surprise bills. 

In addition, your health plan adopts and complies with the surprise billing laws of the District of Columbia.  

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to myuhc.com or contact the health plan at 877-835-9861.

Healthcare FSA (HCFSA) – Reimburses an FSA participant for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, over-the-counter drugs and medications, vision and dental expenses, and much more) for their tax dependents, and their adult children (through the end of the calendar year in which they turn 26).

FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans. This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

No copayments for preventive care services.  This includes items such as, but not limited to, immunizations, physical examinations and screenings as appropriate and recommended by U.S. Preventive Services Task Force. Please refer to Section 5 of the brochure for more detail.

$25 per visit to your Primary Care Provider (PCP) for ages 18 and older, $0 per visit for children under 18

$0 per virtual visit through designated virtual visit providers 

$35 per visit to your specialist 

$150 per day up to $750 per admission

$150 per visit at approved free standing surgical facility

$300 per visit outpatient surgical facility charge at hospital

$350 per visit - waived if admitted

Regular cost sharing

Tier 1: $10; Tier 2: $50; Tier 3: $100; Tier 4: $200

Tier 1: $25

Tier 2: $125

Tier 3: $250

Tier 4: $500

Specialty pharmacy (30-day supply)

Tier 1 $ 10

Tier 2 $150

Tier 3 $350

Tier 4 $500

$35 specialist for eye refraction exam every year

Note: Children have preventive eye examinations as described in the Bright Future Guidelines with 100% coverage

Deductible

Member Pays: No deductible; Brochure Section 9

Primary Care Physician Visit

Member Pays: No deductible; Brochure Section 9

Preventive Care

Member Pays: No deductible; Brochure Section 9

Specialist Visit

Member Pays: Nothing; Brochure Section 9

Virtual Visit

Member Pays: Nothing; Brochure Section 9

Urgent Care

Member Pays: Nothing; Brochure Section 9

Emergency Room

Member Pays: Nothing; Brochure Section 9

Medical Benefit: Pharmacy (30-day supply)

Member Pays: Tier 1 - $5, Tier 2 - $35, Tier 3 - $65, Tier 4 - $100; Brochure Section 9

*Note: You must have Medicare Part A and Part B, and Medicare must be primary for you to enroll in the UnitedHealthcare
Retiree Advantage Plan. This plan reduces your costs by eliminating your cost sharing for covered medical services. Please
see Section 9 in this brochure for additional information on how to enroll in this plan and for details on a reimbursement of
$150.00 of your Medicare Part B premium.

Professional services of physicians

• In your physician’s office/telehealth visit
• Primary care / Optum Primary care
• Office medical consultations
• Second surgical opinion
• Advanced care planning

$25 per primary care provider (PCP) visit for members 18 and older; $0 for children under 18

$35 per specialist visit

Second Opinion Benefit -  You now have access to personalized second opinions by video or by phone through the Second Opinion Program.  Second Opinion is powered by 2nd MD, a third-party-vendor, to assist you with more informed decision making.  The plan pays 100% for this program when the 2nd MD is the provider.  This is an in-network only option.  It does not change your cost sharing costs for your second opinion benefit when utilized through other providers

$0

Professional services of physicians

• In an urgent care center
• During a hospital stay
• In a skilled nursing facility
• At home

$0 - facility fee applies

Virtual visits when :

• Your doctor is not available
• You become ill while traveling
• Conditions such as: cold, flu, bladder infection, bronchitis, diarrhea, fever, pink eye, rash, sinus problem, sore throat, stomach ache

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

Find a Designated Virtual Visit Network Provider Group at myuhc.com or by calling Customer Care at 1-877-835-9861. Virtual Visits and prescription services are subject to state regulations. 

$0 per visit

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• X-rays
• Non-routine mammograms
• Ultrasound
• Electrocardiogram and EEG

$50 per visit

• CT Scans
• MRI/MRA
• PET Scans

Routine physical every year:

The following preventive services are covered at the time interval recommended at each of the links below:

• U.S. Preventive Services Task Force (USPSTF) A and B recommended screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer. For a complete list of screenings go to the website at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women go to the Health and Human Services (HHS) website at https://www.hrsa.gov/womens-guidelines
• To build your personalized list of preventive services go to to https://health.gov/myhealthfinder

$0

One annual biometric screening to include the following services if appropriate based upon age and frequency recommendation:

• Body Mass Index (BMI)
• Blood pressure
• Lipid/cholesterol levels
• Glucose/hemoglobin A1c measurement

Note: Office visit and lab services must be rendered on the same day and coded by your doctor as preventive to be covered in-full

Members can complete their HRA  (Health Risk Assessment) on www.myuhc.com

$0

Routine mammogram 

$0

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC); based on the Advisory Committee on Immunization Practices (ACP) schedule. For a complete list of endorsed immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/

BRCA genetic counseling and evaluation are covered as preventive services  when a woman’s family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes and medical necessity criteria has been met

$0

Note: Any procedure, injection, diagnostic service, laboratory, or x-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

$0

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy,
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.
• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) for cost share requirements for anti-obesity medications.
• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.

$0

Not covered:

• Physical exams and immunizations required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related expenses

All charges

• Well-child visits, examinations and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics.  For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
• Children’s immunizations endorsed by the Centers for Disease Control (CDC) including DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the website at https://www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

$0

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy,
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.
• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) for cost share requirements for anti-obesity medications.
• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.

See Section 5(b) for surgery requirements and cost share

Complete maternity (obstetrical) care, such as:

• Prenatal and Postpartum care
• Screening for gestational diabetes  
• Bacteriuria screening
• Delivery
• Screening and counseling for prenatal and postpartum depression

Note: Here are some things to keep in mind:

• As part of your coverage, you have access to in-network certified nurse midwives, board-certified lactation specialists during the prenatal and post-partum period.
• You do not need to precertify your vaginal delivery; see page 18 for other circumstances, such as extended stays for you or your baby.
• Routine care includes office visits, one office sonogram (as part of prenatal care) and laboratory work. Copays will continue to apply to specialized scanning, any specialist not the member's current OB/GYN, durable medical equipment, prescription drugs, chiropractic and acupuncture services, emergency room visits, urgent care visits, or inpatient hospital copayments as these services are not considered routine.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. 
• We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b) for applicable copayments. 

Note: When a newborn requires definitive treatment during or after the mother's hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits. In addition, circumcision is covered at the same rate as for regular medical or surgical benefits.

$0 for routine prenatal care or the first postpartum care visit

$25 per primary care physician (PCP) visit

$35 per specialist visit

Breastfeeding and lactation support, supplies and counseling for each birth

$0

Contraceptive counseling on an annual basis

$0

A range of voluntary family planning services, without cost sharing, that includes at least one form of contraception in each of the categories on the HRSA list. This list includes: 

• Voluntary female sterilization
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms

Note: See additional Family Planning and Prescription drug coverage Section 5(f).

Note: Your plan offers some type of voluntary female sterilization surgery coverage at no cost to members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any type of voluntary female sterilization surgery that is not already available without cost sharing can be accessed through the contraceptive exceptions process described below.

Contraceptive products that are not already available at $0 cost-share can be provided at $0 member cost-share if the provider determines that a particular contraceptive is medically necessary for that member. The cost-share waiver process requires that providers attest the product is needed for contraceptive purposes and this can be submitted electronically by the provider. To request an exemption, please call customer service at 887-835-9861

If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

$0

Voluntary male sterilization 

$25 per primary care provider (PCP) visit

$35 per specialist visit

Genetic testing is covered when medically necessary for certain conditions such as pregnancy testing for cystic fibrosis, certain autosomal recessive conditions and dominent less penetrant conditions, x-linked conditions and certain chromosome abnormalities.

$35 per specialist visit

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing not medically necessary

Diagnosis and treatment of the cause of infertility

$25 per primary care provider (PCP) visit

$35 per specialist visit

Infertility: A disease (an interruption, cessation, or disorder of body functions, systems, or organs) of the reproductive tract which prevents the conception of a child or the ability to carry a pregnancy to delivery.  It is defined by the failure to achieve a successful pregnancy after 12 months or more of unprotected intercourse or artificial insemination for individuals under age 35.  Earlier evaluation and treatment for those individuals actively looking to achieve a conception may be justified based on medical history and diagnostic testing and is warranted after six (6) months for individuals aged 35 years or older.

Covered Services

Diagnosis and treatment of infertility specific to:

Artificial insemination:

• Intravaginal Insemination (IVI)
• Intracervical Insemination (ICI)
• Intrauterine Insemination (IUI)
  • Fertility drugs (see section 5f)
• Oral and injectable drugs associated with artificial insemination and IVF (3 cycles annually) procedures

Note: Prior Authorization required

50% coinsurance of the plan allowance

• Testing and treatment
• Allergy injections

$25 per primary care provider (PCP); visit for members 18 and older; $0 for children under 18

$35 per specialist visit

$0

Not covered:

• Provocative food testing
• Sublingual allergy desensitization

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 42.

• Respiratory and inhalation therapy (Pulmonary rehabilitation)  is provided for up to 20 visits per year
• Cardiac rehabilitation following qualifying event/condition is provided for up to 36 visits per condition per year
• Dialysis – hemodialysis and peritoneal dialysis
• Cochlear therapy following cochlear implant up to 30 visits per year
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.

Note: We only cover GHT when we preauthorize the treatment.  We will ask you to submit information that establishes that the GHT is medically necessary.  Ask us to authorize GHT before you begin treatment.  We will only cover GHT services and related services and supplies that we determine are medically necessary.  See Other services under You need prior Plan approval for certain services on page 16.

• Applied Behavior Analysis (ABA) - Children with autism spectrum disorder

$35 per specialist visit 

$50 per outpatient facility visit

Up to 60 per year for rehabilitative/habilitative physical /occupational therapy in any combination of the following:

• Qualified physical therapists
• Occupational therapists
• Physician
• Licensed therapy provider

Services must be performed by a physician or by a licensed therapy provider.

Note:  We only cover therapy when a physician: 

• orders the care;
• identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
• indicates the length of time the services are needed.

Benefits can be denied or shortened for covered persons who are not progressing in goal-directed rehabilitative services or if rehabilitation goals have not been met.

We will pay benefits for up to 20 visits of cognitive rehabilitation therapy only when Medically Necessary following sudden External injuries such as car accidents or falls; or sudden internal injuries such as stroke (cerebral vascular accident), aneurysm, anoxia, encephalitis or brain tumors.

 All Therapies are subject to medical necessity.

$35 per specialist visit

Services include:

• Speech therapy
• Occupational therapy; and
• Physical therapy

Includes medically necessary habilitative services coverage for children with Autism, an Autism Spectrum disorder, or Cerebral Palsy

Note: No day or visits apply to these services. A congenital disorder means a significant structural or functional abnormality that was present from birth

$35 per specialist visit

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

Up to 60 visits per calendar year for rehabilitative/habilitative speech therapy.

$35 per specialist visit

Not covered:

• Exercise programs
• Voice therapy

• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist.
• First hearing aid and testing only when necessitated by accidental injury.

Note: for routine hearing screening performed during a child's preventive care visit, see Section 5(a) Preventive care children

• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

Note:  for benefits for the devices, see Section (a) Orthopedic and prosthetic devices.

$25 per primary care provider (PCP) visit for members 18 and older; $0 for children under 18

$35 per specialist visit

Not covered:

• All other hearing aids and testing for them
• Hearing services that are not shown as covered

• Initial pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)
• Annual eye refraction exams

Note: Children examinations are covered at no charge as outlined in the Bright Future Guidelines provided by the American Academy of Pediatrics

      Replacement glasses or contact lenses are not covered after the initial pair.

$25 per primary care provider (PCP) visit for members 18 and older; $0 for children under 18

$35 per specialist visit

Not covered:

• Eyeglasses or contact lenses, except as shown above
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery

$25 per primary care provider (PCP) visit for members 18 and older; $0 for children under 18

$35 per specialist visit

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

• Artificial limbs and eyes
• Prosthetic sleeve or sock 
• Orthopedic devices such as braces, medical supplies including colostomy supplies, dressings, urinary catheters and related supplies
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy
• A hair prosthesis for hair loss resulting from chemotherapy or radiation treatment for cancer.  There is a limit of one hair prosthesis per lifetime with a maximum cost of $350. 
• Bone-anchored hearing aids (BAHA) are covered only when the member has either of the following:
  • Craniofacial anomalies in which abnormal or absent ear canals preclude the use of a wearable hearing aid;
  • Hearing loss of sufficient severity that it cannot be adequately remedied by a wearable hearing aid
  • Benefits limited to one bone anchored hearing aid per member, who meets the above coverage criteria, during the entire period of time the member is enrolled in the health plan.
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical procedures.  For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and ambulance services.

Note:  Plan prior authorization required for items that cost $1,000 or more.

50% of the plan allowance

Not covered:

• Orthopedic and corrective shoes
• Arch supports
• Foot orthotics
• Heel pads and heel cups
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Speech prosthetics (except electrolarynx)
• Prosthetic replacements provided less than 3 years after the last one we covered

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment.  Covered items include: 

• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs
• Crutches
• CPAP
• Walkers
• Blood glucose monitors
• Insulin pumps

Note: Plan prior authorization is required for items that cost $1,000 or more. Repairs and replacements are covered if needed due to a change in the member’s medical condition. Call us at 877-835-9861  as soon as your Plan physician prescribes this equipment.  We will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

50% of the plan allowance

Not covered:

Motorized wheelchairs

Audible prescription reading devices

Hearing aids

Speech generating devices

Talkers

Story boards

Scooters

• Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.
• Skilled care is skilled nursing, skilled teaching and skilled rehabilitation services when all of the following are true:
  • It must be delivered or supervised by a licensed technical or professional medical personnel in order to obtain the specified medical outcome and provide for safety of the patient
  • It is ordered by a physician
  • It is not delivered for the purpose of assisting with activities of daily living including dressing, feeding, bathing or transferring from a bed to a chair
  • It requires clinical training in order to be delivered safely and effectively
  • It is not custodial care
• We will determine if benefits are available by reviewing both the skill nature of the service and the need for Physician directed medical management.  A service will not be determined to be skilled simply because there is not an available caregiver.
• Services include administration of oxygen therapy, intravenous therapy and medications 
• Limit of 60 visits per year

Prescription foods covered as follows: 

• Amino acid modified preparations and low protein modified liquid food products for the treatment of inherited metabolic diseases which are prescribed for the therapeutic treatment of inherited metabolic diseases and are administered under the direction of a physician
• Specialized formulas for the treatment of a disease or condition and are administered under the direction of a Physician
• Medical foods which are determined to be the sole source of nutrition and cannot be obtained without a physician's prescription

$25 per visit 

$25 per prescription food delivery

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family.
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.
• Private duty nursing
• Foods that can be obtained over the counter  (without a prescription) even if prescribed by a physician

• Diagnosis and related services for the manipulation of the spine and extremities to remove nerve interference or its effects. Limited to one treatment per day up to 20 visits per calendar year

Note: The interference must be the result of, or related to, distortion, misalignment, or subluxation of, or in, the vertebral column.

50% of the plan allowance

Acupuncture – by a doctor of medicine or osteopathy, or licensed or certified acupuncture practitioner for up to 12 visits per year :

• Dry Needling – by a licensed or certified practitioner

$35 per specialist visit

Not covered:

• Naturopathic services
• Hypnotherapy
• Biofeedback
• Massage Therapy
• Herbal medicine
• Rolfing
• Ayurveda
• Homeopathy
• Other alternative treatments unless specifically listed as covered

Coverage is provided for:

Tobacco Cessation program which includes online learning, Quit Coach, Nicotine Replacement Therapy Coaching and over the counter and prescription drugs approved by the FDA (subject to age and treatment therapy recommendations) to treat tobacco dependence. Learn more about this program in Section 5(h) Wellness and other Special Features.

$0

• Outpatient self-management training for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and non-insulin using diabetes and other designated chronic health conditions. 
• Must be prescribed by a licensed healthcare professional who has appropriate state licensing authority
• Outpatient self management training includes, but is not limited to, education and medical nutrition therapy.  The training must be provided by a certified registered or licensed healthcare professional trained in the care and management of diabetes.
• Initial training visit; up to 10 hours, after you are diagnosed with diabetes for the care and management of diabetes

$25 per Primary Care Provider (PCP) visit for members 18 and older; $0 for children under 18

$35 per specialist visit

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Insertion of internal prosthetic devices.  See 5(a) Orthopedic and prosthetic devices for device coverage information
• Treatment of burns

Note: For female surgical family planning procedures see Family Planning Section 5(a)

Note: For male surgical family planning procedures see Family Planning Section 5(a)

$35 per specialist visit

Voluntary sterilization women  (tubal ligation)

$0

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot; (see Foot care)

Surgical treatment of severe morbid obesity (bariatric surgery)

Eligible members must be age 18 or older or for adolescents, have achieved greater than 95% of estimated adult height AND a minimum Tanner Stage of 4

• A Body Mass Index (BMI) above 40 kg/m2 without co-morbidity; or
• A BMI of 35 kg/m2 or greater with obesity-related co-morbid medical conditions including:
  • Hypertension
  • Cardiopulmonary condition
  • Sleep apnea
  • Diabetes
  • Any life threatening or serious medical condition that is weight induced
• must enroll in the Bariatric Resource Services Program (BRS)
• must use a designated Bariatric Resource Services (BRS) provider and facility
• Documentation that dietary attempts at weight control have been ineffective through completion of a structured diet program, such as Weight Watchers or Jenny Craig. Either of the following in the two-year period that immediately precedes the request for the surgical treatment of morbid obesity meets the indication:
  • a. One structured diet program for six consecutive months; or
  • b. Two structured diet programs for three consecutive months
• A carrier or a private review agent acting on behalf of a carrier shall use flexibility with regard to defining a structured diet program
• Completion of a psychological examination of the member's readiness and fitness for surgery and the necessary postoperative lifestyle changes

$35 per specialist visit

Revisional Bariatric Surgery due to a technical failure or major complication from the initial procedure; potential failure/complications include but are not limited to the following:

• Bowel perforation (including adjustable gastric band erosion)
• Adjustable gastric band migration (slippage) that cannot be corrected with manipulation or adjustment (records must demonstrate that manipulation or adjustment to correct band slippage has been attempted)
• Leak
• Obstruction (confirmed by imaging studies)
• Staple-line failure
• Mechanical adjustable gastric band failure
• Uncontrollable reflux related to sleeve gastrectomy when all the following criteria are met:
  • Maximum nonpharmacological medical management failure (e.g., positional, dietary modification and behavioral changes); and
  • Maximum pharmacological medical management failure (e.g., at least one month of double dose PPI, H2 blocker, and/or sucralfate); and
  • Severe esophagitis (grade C or D) confirmed by endoscopy despite maximum medical management

The individual must also meet the following criteria:

Both of the following:

• Completion of a preoperative evaluation that includes a detailed weight history along with dietary and physical activity patterns; a
• Psychosocial-behavioral evaluation by an individual who is professionally recognized as part of a behavioral health discipline to provide screening and identification of risk factors or potential postoperative challenges that may contribute to a poor postoperative outcome

$35 per specialist visit

Coverage is available for fertility preservation for medical reasons that cause irreversible infertility such as surgery, including surgical treatment of gender dysphoria, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes.

Covered benefits include the following procedures:

• Collection of sperm
• Cryo-preservation of sperm
• Oocyte cryo-preservation
• Embryo cryo-preservation
• Ovarian stimulation, retrieval of eggs and fertilization

Benefits are not available for:

• Embryo transfer
• Long-term storage costs (greater than 1 year)
• Elective fertility preservation.

Benefits are further limited to one cycle of fertility preservation for iatrogenic infertility per covered person during the period of time he or she is enrolled for coverage under the policy.

There is a benefit limit of $20,000 for medical services and $5,000 for pharmacy benefits. The preimplantation genetic testing and fertility preservations are one combined maximum. Prior authorization is required.

$35 per specialist visit 

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • The condition produced a major effect on the member’s appearance; and
  • The condition can reasonably be expected to be corrected by such surgery.
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts;
  • treatment of any physical complications, such as lymphedemas;
  • breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

$35 per specialist visit

Gender Affirming Surgery

Surgical treatment for Gender Dysphoria may be indicated for individuals who meet the medical criteria and persistent, well-documented diagnostic criteria A disorder characterized by the following diagnostic criteria (Diagnostic and Statistical Manual of Mental Disorders, 5th edition [DSM-5]). 

Requirements:

• Must be 18 years of age or older
• Must have documented evidence of persistent gender dysphoria
• Favorable psychosocial-behavioral evaluation to provide screening and identification of risk factors or potential postoperative challenges
• Persistent, well-documented Gender Dysphoria
• Capacity to make a fully informed decision and to consent for treatment
• Complete at least 12 months of successful continuous full-time real-life experience in the desired gender
• Complete 12 months of continuous cross-sex hormone therapy appropriate for the desired gender (unless medically contraindicated)
• Treatment plan that includes ongoing follow-up and care by a Qualified Behavioral Health Provider experienced in treating Gender Dysphoria*

Gender reconstructive surgeries include:

• Bilateral mastectomy or breast reduction
• Breast augmentation with breast implants or fat transfer
• Chest and breast surgery including bilateral mastectomy
• Clitoroplasty (creation of clitoris)
• Hysterectomy (removal of uterus)
• Labiaplasty (creation of labia)
• Laser or electrolysis hair removal in advance of genital reconstruction prescribed by a physician for the treatment of Gender Dysphoria
• Metoidioplasty (creation of penis, using clitoris)
• Orchiectomy (removal of testicles)
• Penectomy (removal of penis)
• Penile prosthesis
• Phalloplasty (creation of penis)
• Salpingo-oophorectomy (removal of fallopian tubes and ovaries)
• Scrotoplasty (creation of scrotum)
• Testicular prostheses
• Thyroid cartilage reduction/reduction thyroid chondroplasty/tracheal shave (removal or reduction of the Adam’s apple)
• Urethroplasty (reconstruction of female urethra)
• Urethroplasty (reconstruction of male urethra)
• Vaginectomy (removal of vagina)
• Vaginoplasty (creation of vagina)
• Voice lessons and/or voice therapy
• Voice modification surgery (e.g., laryngoplasty, glottoplasty or shortening of the vocal cords)
• Vulvectomy (removal of vulva)
• Gender Affirming Facial Surgeries
• Travel and Lodging ($2000 maximum)

Note: Prior Authorization is required

$35 per specialist visit

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones;
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
• Removal of stones from salivary ducts;
• Excision of leukoplakia or malignancies;
• Dental care necessary to release pain in treatment of temporomandibular joint pain dysfunction;
• Excision of cysts and incision of abscesses when done as independent procedures; and
• Other surgical procedures that do not involve the teeth or their supporting structures.

$35 per specialist visit

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

Services for the evaluation and treatment of TMJ and associated muscles

• Diagnosis: Exam, radiographs and applicable imaging studies and consultation.
• Non-surgical treatment including: Clinical exams, Oral appliances (orthotic splints), Arthrocentesis, Trigger-point injections

Benefits are provided for surgical treatment if the following criteria are met:

• There is radiographic evidence of joint abnormality
• Non-surgical treatment has not resolved the symptoms
• Pain or dysfunction is moderate or severe.

Benefits for surgical services include:

• Arthrocentesis
• Arthroscopy
• Arthroplasty
• Arthrotomy
• Open or closed reduction of dislocations

Services are limited to $3,000 for all TMJ services  - facility fees, durable medical and pharmacy fees will apply

$35 per specialist visit

These solid organ transplants are covered.  Solid organ transplants are limited to:  

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart/lung
• Intestinal transplants
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas

• Kidney
• Kidney-pancreas
• Liver
• Lung: single/bilateral/lobar
• Pancreas

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical review by the Plan.  Refer to Other services in Section 3 for your authorization procedures.

• Autologous tandem transplants for
  • AL Amyloidosis
  • Multiple myleoma (de novo and treated)
  • Recurrent gem cell tumors (including testicular cancer)

$35 per specialist visit

Blood or marrow stem cell transplants

the plan extends coverage for the diagnoses as indicated below:.

• Allogenic transplants for 
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hematopoietic stem cell
  • Hemoglobinopathy
  • Infantile malignant osteopetrosis
  • Kostmann’s syndrome
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome

$35 per specialist visit

• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphoma with reccurrence (relapsed)
  • Advanced non-Hodgkin's lymphoma with reccurrence (relapsed)
  • Amyloidosis
  • Breast cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing's sarcoma
  • Hematopoietic stem cell 
  • Medulloblastoma
  • Multiple myeloma
  • Pineoblastoma
  • Neuroblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

$35 per specialist visit

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan.

Refer to Other services in Section 3 for prior authorization procedures:

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with reccurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with reccurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi’s, PNH, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with reccurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with reccurrence (relapsed)
  • Amyloidosis
  • Neuroblastoma

$35 per specialist visit

These blood or marrow stem cell transplants covered only in a National Cancer Institute or National Institutes of Health approved clinical trial or a Plan-designated center of excellence if approved by the Plan’s medical director in accordance with the Plan’s protocols. 

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient's condition) if it is not provided by the clinical trial.  Section 9 has additional information on costs related to clinical trials.  We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

• Allogeneic transplants for
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Beta Thalassemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Sickle Cell Anemia
• Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning RIC) for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL )
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma  
  • Multiple myeloma
  • Multiple sclerosis
  • Myelodysplasia/Myelodysplactic Syndromes
  • Myeloproliferative disorders (MDDs)
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle Cell anemia
•  Autulogous Transplants for
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Aggressive non-Hodgkin's lymphoma
  • Breast Cancer
  • Childhood rhabdomyosarcoma
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial ovarian cancer
  • Mantle Cell (Non-Hodgkin lymphoma)
  • Multiple sclerosis
  • Small cell lung cancer
  • Systemic lupus erythematosus
  • Systemic sclerosis

National Transplant Program (NTP) - OptumHealth Care Solutions (URN) used for organ tissue transplants

Limited Benefits - Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in a National Cancer Institute - or National Institutes of Health - approved clinical trial at a Plan-designated center of excellence and if approved by the Plan's medical director in accordance with the Plan's protocols.

Note: We cover related medical and hospital expenses of the donor when we cover the recipient.  We cover donor testing for the actual solid organ donor.  Transplants must be provided in a Plan designated Center for Transplants.  These centers do a large volume of these procedures each year and have a comprehensive program of care.  A listing of these centers can be found in the Plan Directory of Health Care Providers, at our member web site www.myuhc.com or call our Customer Service Department at 1-877-835-9861 to request an up-to-date listing.

$35 per specialist visit

Note:  Donor testing for bone marrow/stem cell transplants for up to 4 potential donors whether family or non-family 

50% of the plan allowance

Not covered:

• Donor screening tests and donor search expenses, except as shown above
• Implants of artificial organs
• Transplants not listed as covered
• All services related to non-covered transplants
• All services associated with complications resulting from the removal of an organ from a non-member

Professional services provided in:

• Hospital (inpatient)
• Hospital (outpatient department)
• Skilled nursing facility
• Ambulatory surgical center
• Office

$35 per specialist visit

Room and board, such as

• Ward, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

$0

Not covered:

• Custodial care
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as phone, television, barber services, guest meals and beds
• Private nursing care unless medically necessary

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays, and pathology services
• Administration of blood, blood plasma, and other biologicals
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

$150 per outpatient surgical charge at approved free standing surgical facility

$300 per outpatient surgical charge at hospital

• Room and board in a semi-private room
• General nursing
• Drugs, biologicals, supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor
• Benefits up to 60 days when full time skilled nursing care is necessary and confinement is medically appropriate.

$0 when transferred directly from inpatient

$150 per day for up to $750 per admission if not transferring from inpatient

• Inpatient care
• Outpatient care
• Family counseling
• Supportive and palliative care for a terminally ill member is covered in the home or hospice

$0 when transferred directly from hospital 

$150 per day up to 5 days per admission to facility if not transferring from hospital

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, including transportation costs of a newborn to the nearest appropriate facility to treat the newborn’s condition. The Physician must certify that such transportation is necessary to protect the health and safety of the newborn. 

• 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. 

• Prior Authorization Requirement In most cases, we will initiate and direct non-Emergency ambulance transportation. If you are requesting non-Emergency ambulance services, you must obtain authorization as soon as possible before transport. If you do not obtain prior authorization as required, you will be responsible for paying all charges and no Benefits will be paid.

 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.

$0

Not Covered:

International Transportation

All charges

• Emergency care at a doctor’s office

$25 per primary care provider (PCP) visit; $35 per specialist visit

• Emergency care at an urgent care center

$35 per visit

• Emergency care as an outpatient at a hospital, including doctors’ services

$350 per visit

• Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges

Emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance or water vehicle) to the nearest Hospital where the required Emergency Health Care Services can be performed.

$500 copayment for Air Ambulance

Not Covered:

International Transportation

All Charges

When part of a treatment plan we approve, we cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders. Services include:

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual or group therapy visits in office or telemedicine)
• Diagnosis and treatment of substance abuse disorders, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider's office or other professional setting
• Electroconvulsive therapy

$25 per visit

$150 per day up to 5 days per inpatient admission

• Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

$0

Inpatient services provided and billed by a hospital or other covered facility

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
• Services in approved half-way house, residential treatment, full-day hospitalization, partial hospitalization

Outpatient services provided and billed by a hospital or other covered facility

• Services in facility-based intensive outpatient treatment

$0 per visit

• Psychiatric evaluation or therapy on court order or as a condition of parole or probation, unless determed by a Plan physician to be necessary and appropriate
• Services and supplies when paid for directly or indirectly by a local, State, or Federal Government agency.
• Room and board at therapeutic boarding schools
• Services rendered or billed by schools
• Services that are not medically necessary
•  Methodone maintenance unless it is a part of an approved treatment program

All charges

Note: Note: Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a health care professional and filled by a network pharmacy.

These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients.  For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

The following drugs and supplements are covered without cost-share, even if over-the-counter, are prescribed by a healthcare professional and filled at a network pharmacy.

• Aspirin (81 mg) for men age 45-79 and women age 55-79 and women of childbearing age

• Folic acid supplements for women of childbearing age 400 & 800 mcg

• Liquid iron supplements for children age 0-1 year

• Pre-natal vitamins for pregnant women

• Fluoride tablets, solution (not toothpaste, rinses) for children age 0-6

• Certain statins to treat cardiovascular disease for adults age 40 to 75 will be covered without a copayment as recommended by the United States Preventive Services Task force ( USPSTF) when the following criteria is met: Age 40 to 75 years; and one or more CVD risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking); and a calculated 10-year risk of a cardiovascular event of 10% or greater.

Note: To receive this benefit a prescription from a doctor must be presented to pharmacy. Benefits available at in-network pharmacy only.

$0

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order program:

• Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered.
• Insulin with a copayment charge applied every 2 vials
• Disposable needles and syringes for the administration of covered medications
• Drugs for sexual dysfunction are limited.  Contact the plan for dosage limits.
• Drugs to treat gender dysphoria*
  • Estradiol
  • testosterone
  • leuprolide
• Oral and injectable contraceptive drugs
• Drugs used for Gender Dysphoria - may require prior authorization and may be covered under the specialty drug benefits
• oral and injectable drugs associated with artificial insemination and IVF (3 cycles annually) procedures
• Medications prescribed to treat obesity*
  • Saxenda
  • Wegovy
  • Zepbound

Prior Authorization is required 

Note: Intravenous fluids and medications for home use, implantable drugs, and some injectable drugs are covered under Medical services and supplies Section (5a) or Surgical and anesthesia services Section (5b).

*For a complete list of drugs and medications, visit www.uhcfeds.com or call our Customer Service Department 877-835-9861

Plan retail pharmacy up to a maximum of a 30-day supply:

Tier 1- $10

Tier 2- $50

Tier 3- $100

Tier 4 -$200

Plan mail order pharmacy for up to a maximum of up to a 90-day supply:

Tier 1- $25

Tier 2- $125

Tier 3- $250

Tier 4- $500

Specialty Medications (up to a 30-day supply)

Tier 1 $10

Tier 2 $150

Tier 3 $350

Tier 4 $500

COVID-19 Over The Counter (OTC) Test Kits

• 8 Tests per member per month

Tier 3 -$12 Capped

Contraceptive drugs and devices as listed in the Health Resources and Services Administration site https://www.hrsa.gov/womens-guidelines.

Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below.

• Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.
• If you have difficulty accessing contraceptive coverage or other reproductive healthcare you can contact contraception@opm.gov.
• Reimbursement for over-the-counter contraceptives can be submitted in accordance with Section 7. By completing a claim form and submitting the form with receipts to OptumRx, PO Box 29044, Hot Springs, AZ 71903. You can reach out to customer service at 877-835-9861 to obtain a prescription drug claim form.
• Members may have a clinical review for contraceptives that are excluded. They should reach out to their prescribing provider. Contraceptive products that are not already available at $0 cost-share can be provided at $0 member cost-share if the provider determines that a particular contraceptive is medically necessary for that member. The cost-share waiver process requires that providers attest the product is needed for contraceptive purposes and this can be submitted electronically by the provider

Note: For additional Family Planning benefits see Section 5(a)

$0

• Diabetic supplies limited to insulin syringes, needles, glucose test tape, Benedict’s solution or equivalents and acetone test tablets.

50% of the plan allowance

Prescription tobacco cessation medications and FDA approved over the counter tobacco cessation medications with prescription from physician. Note quantity limits and age restrictions may apply.

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation Educational Classes and Programs in Section 5(a)

$0

Not covered:

• Drugs and supplies used for cosmetic purposes
• Drugs to enhance athletic performance
• Medical supplies such as dressings and antiseptics
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Prescription Drug Products as a replacement for a previously dispensed Prescription Drug Product that was lost, stolen, broken or destroyed
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them 
• Drugs available over-the-counter that do not require a prescription order by federal or state law before being dispensed, and any drug that is therapeutically equivalent to an over- the-counter 
• Compound drugs that do not contain at least one covered ingredient that requires a Prescription Order or Refill
• Alcohol swabs and bio-hazard disposable containers
• Medical Marijuana
• Drugs for sexual performance for patients that have undergone genital reconstruction
• Nonprescription medications unless specifically indicated elsewhere

Opioid rescue agents such as naloxone are covered under this Plan with no cost sharing when obtained from a [network] pharmacy in any over-the-counter or prescription form available such as nasal sprays and intramuscular injections.

For more information consult the FDA guidance at https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/

$0

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury and  

• The dental damage is severe enough that initial contact with a Physician or dentist occurred within 72 hours of the accident. You may request an extension of this time period provided you do so within 60 days of the injury and if extenuating circumstances exist (such as prolonged hospitalization or the presence of fixation wire from fracture care.)
• Benefits for treatment of accidental injury are limited to the following:
  • Emergency examination
  • Necessary X-rays
  • Endodontic (root canal) treatment
  • Temporary splinting of teeth
  • Prefabricated post and core
  • Simple minimal restorative procedures (fillings)
  • Extractions
  • Placement of a crown if such treatment is the only clinical treatment and in cases of an injury as described above in this section
  • Replacement of lost teeth due to injury
  • Dental services are received from a Doctor of Dental Surgery or Doctor of Medical Dentistry

A sound natural tooth is defined as a tooth that:

• has no active decay, has at least 50% bony support,
• has no filling on more than two surfaces;
• has no root canal treatment, is not an implant
• is not in need of treatment except as a result of the accident, and
• functions normally in chewing and speech.
• Crowns, bridges, implants and dentures are not considered sound natural teeth

Not covered:

• Oral implants and related procedures, including bone grafts to support implants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingival and aveolar bone)

Benefits for dental care that is medically necessary and an integral part of the treatment of a sickness or condition for which covered health services are provided. 

Examples of adjunctive dental care are:

• Extraction of teeth prior to radiation for oral cancer
• Elimination of oral infection prior to transplant surgery
• Removal of teeth in order to remove an extensive tumor

Note: When alternate methods may be used, we will authorize the least costly covered health service provided that the service and supplies are considered by the profession to be an appropriate method of treatment and meet broadly accepted national standards of dental practice.  You and the provider may choose a more expensive level of care, but benefits will be payable according to these guidelines. 

$35 per specialist visit

At home and on the go our digital resources can help you manage health and finances. You want to have the resources to make well informed financial and health care decisions

 At UnitedHealthcare, our mission is helping people live healthier lives®. We strive to make health care simpler and easier for you to understand with our suite of integrated consumer tools on myuhc.com®. For members who are on the go, digital resources are available on the UnitedHealthcare app — wherever and whenever they need to manage your health care.

Download the UnitedHealthcare app* for access to health plan ID cards, benefits information and help answering questions.

At home and on the go our digital resources can help you manage health and finances. You want to have the resources to make well informed financial and health care decisions

The mobile app is designed to help you manage different aspects of your health, like searching for providers and getting health care cost estimates for specific treatments and procedures.

You will have access to your health plan ID card, claims information and real-time status on account balances, deductibles and out-of-pocket spending.  You can find and receive care, estimate costs and pay bills directly from the app. 

Virtual visits can be scheduled and held from your mobile app. (24/7 virtual visits).  Register with one of the UHC providers and visits are available when you are. You can reach out to an advocate from your mobile app as well.

Download the UnitedHealthcare app from the App Store® or Google Play™

Your online web portal can assist to Find Care and Costs to help you find and price care, at the same time. Located on myuhc.com, you can:

Your personalized website, myuhc.com®, features tools designed to help you:

• Find, price and save on care — you can save with Virtual Visits and other tools. You can save an average of 36% * 1 when you compare costs for providers and services • Get care from anywhere with Virtual Visits. A doctor can diagnose common conditions by phone or video 24/7
• Understand your benefits and the financial impact of care decisions
• Find tailored recommendations regarding providers, products and services. You can even generate an out-of-pocket estimate based on your specific health plan status
• Access claim details, plan balances and your health plan ID card quickly
• Follow through on clinical recommendations and access wellness programs
• Order prescription refills, get estimates and compare medication pricing
• Check your plan balances, access financial accounts and more
• Find a quality doctor, clinic, hospital or lab that helps meet their needs.

• Use multiple search options to filter results by location, specialty, quality, cost, services offered and more.
• See provider ratings created by patients.
• Review cost and care options before making an appointment to help control spending and choose the right level of service.

• Access personalized cost and provider information specific to the benefit plan.

With myuhc.com®, your personalized member website, behavioral health support services are available for you and your family to access anytime, anywhere — whether you’re in a time of greater need or may want to work on personal growth. myuhc.com is available at no additional cost to you and your family.
Find the right care for you
Using the provider search tool, you can:

•  Locate therapists, psychiatrists or other behavioral health clinicians and facilities near you
•  Narrow your search by provider name, location, area of expertise and more
•  Schedule an in-person or virtual appointment with the provider you select

Tap into behavioral health support
See which benefits and programs you may be eligible for at myuhc.com. Once there, you can also visit your personalized emotional support page to explore the resources and tools that may help you with the ins and outs of everyday life — even if you might not have any pressing concerns.

Tools and resources at your fingertips: Learn about a variety of behavioral health and well-being topics at myuhc.com Health Resources>Mental Health and Substance Use

• You’ll get access to:

• Articles
• Podcasts
• Videos
• Other tools

To find behavioral health care, sign in or register on myuhc.com and then go to Find Care & Costs>Behavioral Health Directory

Support for those looking to manage day-to-day stress or those who need but are not yet ready to seek treatment or are looking for an adjunct to treatment. This program delivers personalized, on-demand support that can be accessed anytime, anywhere to help you build resilience with new skills and daily habits.

• Assessments and tracking
• Mental health skills and tools – Cognitive Behavioral Therapy skills, mediations and mindful techniques and sleep tracking
• Interactive activities and content to assist with specific needs such as parenting stress, work-related burnout or coping with social injustice
• Community support – Peer to peer sharing and learning, see others’ experiences.

Real Appeal® provides tools and support to help members lose weight and prevent weight- related health conditions. Real Appeal is provided at no additional cost to eligible members as part of your medical benefit plan.
The program can help motivate members to improve their health and reduce risk of developing costly, chronic conditions like cardiovascular disease and diabetes. The program combines clinically proven science with engaging content that teaches members how to eat healthier and be active, without turning their lives upside down, to help them achieve and maintain their weight-loss goals.

Real Appeal includes:

Social community resources such as: Real Appeal LinkedIn community; Facebook community; YouTube videos including getting started, workouts and success stories

A Success Kit - After attending their first group coaching session, members receive a Success Kit with tools to help them kick-start their weight loss. The kit includes items such as:

• Balanced Portion plate
• Electronic food scale
• Digital weight scale
• Fitness guide

A personalized Health Coach - Coaches guide members through the program step-by-step, customizing it to help fit their needs, personal preferences, goals and medical history.
24/7 online support and mobile app through our myuhc portal or directly through our myuhc mobile app. Staying accountable to goals may be easier than ever..
• Customizable food, activity, weight and goal trackers.
• Unlimited access to digital content.
• An online lifestyle program to help you learn new ways to be your healthiest self

Quit for Life provides our members with resources and support for tobacco cessation. Included are:

• Portal and mobile app
• Online learning with interactive and personalized content and a community support forum
• Integrated online and telephonic experience
• Live coaching sessions with coaches with degrees in counseling, addiction studies, and related fields
• Nicotine replacement therapy counseling
• 24/7 support for easier access to services
• Nicotine replacement therapy both prescription medications and over the counter products (with prescription)

Get started today. Go to myuhc.com, visit the "Health Resources" tab on the top right, Choose the "Quit for Life" tile.

Maternity Health Solutions is designed to help improve outcomes and lower costs by providing moms-to-be with personalized care for clinical, behavioral and other holistic needs.

• Maternity-related courses available on myuhc.com regarding course topics such as:
  • Preconception: Preparing for a healthy pregnancy
  • Pregnancy in the first trimester
  • Pregnancy in the second trimester
  • Pregnancy in the third trimester
  • The fourth trimester after pregnancy: Postpartum
  • Pregnancy nutrition and exercise
  • Exploring breastfeeding
• Maternity risk assessment on Myuhc.com
• Additional support for high-risk cases

Choosing a doctor is one of the most important health decisions you’ll make. The UnitedHealth Premium^® program can help you find doctors who are right for you and your family. You can find quality, cost-efficient care. Studies show that people who actively engage in their health care decisions have fewer Hospitalizations, fewer emergency visits, higher utilization of preventive care and overall lower medical costs. 

The program evaluates physicians in various specialties using evidence-based medicine and national standardized measures to help you locate quality and cost-efficient providers. It’s easy to find a UnitedHealth Premium Care Physician. Just go to myuhc.com^® and click on Find a Doctor.  Choose smart. Look for blue hearts.

• Premium Care Physician meets UnitedHealth Premium program quality & cost efficient care criteria.
• Quality Care Physician meets UnitedHealth Premium program quality care criteria, but does not meet the program’s cost efficient care criteria or is not evaluated for cost-efficient care. Physician is not eligible for a Premium designation.
• Not Evaluated for Premium Care physician’s specialty is not evaluated and/or does not have enough claims data for program evaluation or the physician’s program evaluation is in process

What are the benefits of using Optum Specialty Pharmacy?

Optum Specialty Pharmacy provides personalized support and resources at no extra cost to help you manage your condition.

 How does Optum Specialty Pharmacy support you?

• Pharmacists to answer questions 24/7
• A clinical care team to help you understand your medication
• 1-on-1 video chats with your care team
• Helpful videos from other specialty patients
• Supplies you may need to take your medication at no extra cost
• Refill reminders
• Talk with a nurse about infusion services, if applicable

Tips for working with our Optum Specialty Pharmacy care team.

• Tell your pharmacist or nurse about any side effects or issues you may be facing with your care, such as forgetting to take your medication.

• We’re here to help with more than your medication. Our pharmacists and nurses can help you find resources to stay on track with your health.

We’re here to help. Call Optum Specialty Pharmacy at 1-855-427-4682 to learn more and transfer your prescriptions. Or, call the number on the back of your member ID card to find a designated specialty pharmacy near you.

Under the flexible benefits option, we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms. Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit, we cannot guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claims process (see Section 8).

To be a qualifying clinical trial, a trial must meet the following criteria:

Be sponsored and provided by a cancer center that has been designated by the National Cancer Institute (NCI) as a Clinical Cancer Center or Comprehensive Cancer Center or be sponsored by any of the following:

• National Institutes of Health (NIH). (Includes National Cancer Institute (NCI).)
• Centers for Disease Control and Prevention (CDC).
• Agency for Healthcare Research and Quality (AHRQ).
• Centers for Medicare and Medicaid Services (CMS).
• Department of Defense (DOD).
• Veterans Administration (VA).
• The clinical trial must have a written protocol that describes a scientifically sound study and have been approved by all relevant institutional review boards (IRBs) before participants are enrolled in the trial. We may, at any time, request documentation about the trial to confirm that the clinical trial meets current standards for scientific merit and has the relevant IRB approvals. Benefits are not available for preventive clinical trials.
• The subject or purpose of the trial must be the evaluation of an item or service that meets the definition of a Covered Health Service and is not otherwise excluded under the Policy.

Receive reimbursement for your Medicare Part B Premium

• $150.00 will be paid on your behalf directly to Medicare
• See a reduction in your quarterly Medicare bill, or an increase in your Social Security payment or annuity payment

Receive this benefit for every month you’re enrolled in the plan

Renew Active is a fitness benefit which is included in the Medicare Advantage plan which provides:

• A free gym membership to participating facilities
  • To view participating facilities, please visit www.uhcrenewactive.com
• Access to an extensive network of gyms and fitness locations near members
• A personalized fitness plan
• Access to a wide variety of fitness classes
• An online brain health program, exclusively from AARP® Staying Sharp
• Connecting with others at local health and wellness events, and through the Fitbit® Community for Renew Active

Shop for hundreds of over-the-counter items such as toothpaste, vitamins, and personal care from the Health Products catalog.

• Members will receive $40 allowance each quarter to spend on items from the provided catalog
• Items are delivered directly to your door
• Orders can be place over the phone, by mail, or online

With the UnitedHealthcare® HouseCalls program, you get an annual in-home preventive care visit from one of our health care practitioners at no extra cost.

 What does HouseCalls include?

• One 45 to 60-minute at-home visit from a health care practitioner, each year.
• A head-to-toe exam, health screenings and plenty of time to talk about your health questions.
• A custom care plan made just for you.
• Help connecting you with additional care you may need.

Healthy at Home provides the following benefits up to 30 days following all inpatient and skilled nursing facility discharges when referred by a UnitedHealthcare Advocate:

• Home-Delivered Meals
  Receive 28 home-delivered meals provided by Mom’s Meals
• Non-emergency transportation
  Receive 12 one-way rides to medically related appointments and to the pharmacy provided by ModviCare
• In-home Personal Care
• Receive 6 hours of in-home personal care through our exclusive national provider CareLinx

Real Appeal is a weight loss program that can help members feel and look better. The program provides everything they need to lose weight and keep it off. This program is a pilot for select members residing in Wisconsin.

 The online program includes:

• Personalized diabetes prevention coaching
• 24/7 online support and mobile app
• Customizable food, activity, weight and goal trackers
• Success group support, which lets members chat with others who are doing the Real Appeal program
• The weekly Real Appeal All-Star Show featuring healthy tips from celebrities, athletes and health experts

 Success Kit includes:

• Program, nutrition, and fitness guides
• Tools to help cook healthier, tasty meals
• Delivered right to their front door after attending their first group coaching session

UnitedHealthcare Hearing provides members with greater technology, choice and convenience

• Rechargeable hearing aids, remote adjustments and other advanced feature devices are available at up to 80% less than standard industry prices through direct delivery, including top brands in multiple styles
• 6,500+ locations nationwide
• Chose home delivery or in person options
• 3-minute online hearing test to assess hearing loss/need for in-person test
• Members receive $1500 allowance every 36 months towards the purchase of hearing aids
• Members must use a UHC hearing provider to use their hearing aid benefit

Quit For Life has helped 3.5 million members quit smoking or using tobacco. It provides the tools and one-on-one support to help you quit your way.

And for UnitedHealthcare members, it’s offered at $0 out of pocket.

With a 95% satisfaction rate, Quit for Life provides

• Tools and support to help members quit cigarettes, e-cigarettes, vaping and tobacco
• A personal, one-on-one Quit Coach to help you create a customized quit plan
• The Quit for Life mobile app, which offers 24/7 urge management support
• Text2Quit text messages for daily tips and encouragement
• Quit medications – Such as nicotine gum or patches – for no charge, based on eligibility.

UnitedHealthcare^® works with Lifeline to provide a personal emergency response system at no cost for Retiree Advantage plan members

Lifeline personal emergency response system (PERS) allows you to ask for help whenever you need it, anytime of day or night – 365 days of the year, 24/7. All you need to do is press the help button, worn as a wristband or pendant, and a Trained Care Specialist will assist you to make sure you quickly get the help you need.

Features include:

Optional AutoAlert fall detection technology automatically provides access to help if it detects a fall – even if wearer is disoriented, immobilized or unconscious and cannot press their help button

          Cellular or landline compatible, Lifeline works anywhere in the U.S., where current telephone service is provided

          Lightweight, waterproof help button can be worn on the wrist or as a pendant

Your health plan comes with a new way to earn up to $300. With UnitedHealthcare Rewards, you can earn up to $300 for tracking your steps or sleep, getting an annual checkup and more. The activities you go for are up to you. When you activate UHC Rewards, you can also get started with One Pass Select™, a fitness program that gives you unlimited access to a nationwide network of thousands of fitness centers. Plus, you can use your earnings to help pay for a One Pass Select membership.

Start earning with UHC Rewards by:

• Download the UnitedHealthcare® app and then: Sign in or register
• Select UHC Rewards
• Activate UHC Rewards
• Select Redeem rewards to access One Pass Select

UnitedHealthcare Rewards is a voluntary program. The information provided under this program is for general informational purposes only and is not intended to be nor should be construed as medical advice. You should consult an appropriate health care professional before beginning any exercise program and/or to determine what may be right for you. If any fraudulent activity is detected (e.g., misrepresented physical activity), you may be suspended and/or terminated from the program. If you are unable to meet a standard related to health factor to receive a reward under this program, you might qualify for an opportunity to receive the reward by different means. You may call us toll-free at 1-866-230-2505 or at the number on your health plan ID card, and we will work with you (and, if necessary, your doctor) to find another way for you to earn the same reward. Rewards may be limited due to incentive limits under applicable law. Components subject to change. This program is not available for fully insured members in Hawaii, Vermont and Puerto Rico.

One Pass Select is a voluntary program featuring a subscription-based nationwide gym network, digital fitness and grocery delivery service. The information provided under this program is for general informational purposes only and is not intended to be nor should it be construed as medical advice. Individuals should consult an appropriate health care professional before beginning any exercise program and/or to determine what may be right for them. Purchasing discounted gym and fitness studio memberships, digital fitness or grocery delivery services may have tax implications. Employers and individuals should consult an appropriate tax professional to determine if they have any tax obligations with respect to the purchase of these discounted memberships or services under this program, as applicable. One Pass Select is a program offered by Optum. Subscription costs are payable to Optum.

In most cases, providers and facilities file claims for you. Provider must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, call us at 1-877-835-9861.

When you must file a claim – such as for services you received outside the Plan’s service area – submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

• Covered member’s name, date of birth, address, phone number and ID number;
• Name and address of the provider or facility that provided the service or supply;
• Dates you received the services or supplies;
• Diagnosis;
• Type of each service or supply;
• The charge for each service or supply;
• A copy of the explanation of benefits, payments, or denial from any primary payor – such as the Medicare Summary Notice (MSN);
• Receipts, if you paid for your services.

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

Submit your claims to: UnitedHealthcare, P.O. Box 30555, Salt Lake City, UT 84130-0555.

We will notify you of our decision within 30 days after we receive the claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review as long as we notify you before the expiration of the original 30-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

 You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us. For urgent care claims, a healthcare professional with knowledge of your medical condition will be permitted to act as your authorized representative without your express consent. For the purposes of this section, we are also referring to your authorized representative when we refer to you.

If you live in a county where at least 10% of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language.  You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language.  The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.

Ask us in writing to reconsider our initial decision. You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at: UnitedHealthcare Federal Employees Health Benefits (FEHB) Program Appeals, P.O. Box 30573, Salt Lake City, UT 84130-0573 ; and

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

e)  Your email address, if you would like to receive our decision via email.  Please note that by providing your email address, you may receive our decision more quickly.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision.  We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date.  However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration.  You may respond to that new evidence or rationale at the OPM review stage described in step 4.

In the case of a post-service claim, we have 30-days from the date we receive your request to:

a) Pay the claim or  

b) Write to you and maintain our denial or.

c) Ask you or your provider for more information

You or your provider must send the information so that we receive it within 60-days of our request.  We will then decide within 30 more days.

If we do not receive the information within 60-days we will decide within 30-days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

• 90-days after the date of our letter upholding our initial decision; or
• 120-days after you first wrote to us -- if we did not answer that request in some way within 30-days; or
• 120-days after we asked for additional information

Write to OPM at: United States Office of Personnel Management, FEHB 3, 1900 E Street, NW, Washington, DC 20415-3630. 

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM’s decision via email.  Please note that by providing your email address, you may receive OPM’s decision more quickly.

Note:  If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note:  You are the only person who has a right to file a disputed claim with OPM.  Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.  However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note:  The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct.  OPM will send you a final decision or notify you of the status of OPM's review within 60 days.  There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue.  If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval.  This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision.  This information will become part of the court record.

You may not sue until you have completed the disputed claims process.  Further, Federal law governs your lawsuit, benefits, and payment of benefits.  The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision.  You may recover only the amount of benefits in dispute.

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays healthcare expenses without regard to fault. This is called “double coverage.”

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines.  For more information on NAIC rules regarding the coordination of benefits, visit our website at myuhc.com.  

When this Plan is primary, it determines payment for its benefits first before those of any other Plan without considering any other Plan's benefits.  When this Plan is secondary, it 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.

If you elect to enroll in the UnitedHealthcare Retiree Advantage plan, your FEHB plan will not coordinate benefits. The UnitedHealthcare Retiree Advantage plan will take over as the primary and only payer.

TRICARE is the healthcare program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. IF TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

Every job-related injury or illness should be reported as soon as possible to your supervisor. Injury also means any illness or disease that is caused or aggravated by the employment as well as damage to medical braces, artificial limbs and other prosthetic devices. If you are a federal or postal employee, ask your supervisor to authorize medical treatment by use of form CA-16 before you obtain treatment. If your medical treatment is accepted by the Dept. of Labor Office of Workers’ Compensation (OWCP), the provider will be compensated by OWCP. If your treatment is determined not job-related, we will process your benefit according to the terms of this plan, including use of in-network providers. Take form CA-16 and form OWCP-1500/HCFA-1500 to your provider, or send it to your provider as soon as possible after treatment, to avoid complications about whether your treatment is covered by this plan or by OWCP.

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or
• OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

If you have received benefits or benefit payments as a result of an injury or illness and you or your representatives, heirs, administrators, successors, or assignees receive payment from any party that may be liable, a third party’s insurance policies, your own insurance policies, or a workers’ compensation program or policy, you must reimburse us out of that payment.  Our right of reimbursement extends to any payment received by settlement, judgment, or otherwise.

We are entitled to reimbursement to the extent of the benefits we have paid or provided in connection with your injury or illness.  However, we will cover the cost of treatment that exceeds the amount of the payment you received.

Reimbursement to us out of the payment shall take first priority (before any of the rights of any other parties are honored) and is not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned.  Our right of reimbursement is not subject to reduction based on attorney fees or costs under the “common fund” doctrine and is fully enforceable regardless of whether you are “made whole” or fully compensated for the full amount of damages claimed.

We may, at our option, choose to exercise our right of subrogation and pursue a recovery from any liable party as successor to your rights.

Some FEHB plans already cover some dental and vision services. When you are covered by more than one dental/vision plan, coverage provided under your FEHB Plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on BENEFEDS.com or by phone at 1-877-888-3337, (TTY 1-877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application. 

If you are a participant in a clinical trial, and the related care is not covered within the clinical trial, this plan will provide coverage for related costs based on the criteria listed below.

• Routine care costs - costs for routine services such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient's condition, whether the patient is in a clinical trial or is receiving standard therapy.  These costs are covered by the plan.
• Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient  may need as part of the trial, but not as part of the patient's routine care.  This plan does not cover these costs.
• Research costs- costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes are considered research costs.  This plan does not cover these costs.

For more detailed information on “What is Medicare?” and “Should I Enroll in Medicare?” please contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary.  This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something to file your claim, call us at 877-835-9861 or see our Web site at www.uhcfeds.com. 

We do not waive any costs if the Original Medicare Plan is your primary payor.

Please review the following table it illustrates your cost share if you are enrolled in Medicare Part B. Medicare will be primary for all Medicare eligible services. Members must use providers who accept Medicare’s assignment.

We offer a plan designed to help members with their Medicare Part B premium. This plan is called, UnitedHealthcare Retiree Advantage. If you have Medicare Parts A and B primary and enroll in the UnitedHealthcare Retiree Advantage, you will be reimbursed $150.00 of your Medicare Part B monthly premium. Part B reimbursements will begin approximately 90 days following the approval of your Retiree Advantage application.

To learn more about UnitedHealthcare Retiree Advantage and how to enroll, call us at 1-844-481-8821, 8 a.m. to 8 p.m., local time 7 days per week,  For TTY for the deaf, hard of hearing, or speech impaired, call 711. We will send you additional information

Benefit Description: Deductible
High Option You Pay Without Medicare: No deductible
High Option You Pay With Medicare Part B: No deductible

Benefit Description: Out-of-Pocket Maximum
High Option You Pay Without Medicare: $5,000 self only/$10,000 family
High Option You Pay With Medicare Part B: $5,000 self only/$10,000 family

Benefit Description: Part B Premium Reimbursement Offered
High Option You Pay Without Medicare: N/A
High Option You Pay With Medicare Part B: N/A

Benefit Description: Primary Care Provider
High Option You Pay Without Medicare: $25
High Option You Pay With Medicare Part B: $25

Benefit Description: Specialist
High Option You Pay Without Medicare: $35
High Option You Pay With Medicare Part B: $35

Benefit Description: Inpatient Hospital
High Option You Pay Without Medicare: $150 per day up to $750 per admission
High Option You Pay With Medicare Part B: $150 per day up to $750 per admission

Benefit Description: Outpatient Hospital
High Option You Pay Without Medicare: $150 free standing; $300 hospital based
High Option You Pay With Medicare Part B: $150 free standing; $300 hospital based

Benefit Description: Incentives offered
High Option You Pay Without Medicare: N/A
High Option You Pay With Medicare Part B: N/A

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country.

To learn more about Medicare Advantage plans, contact Medicare at 1-800-MEDICARE 800-633-4227, TTY 1-877-486-2048 or at  www.medicare.gov or UnitedHealthcare Retiree Solutions at 844-481-8821.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and our Retiree Advantage plan: If you enroll in our Medicare Advantage plan you MUST also remain enrolled in our FEHB plan. Do not suspend or terminate your FEHB coverage.  For more information on our Medicare Advantage plan, please contact us at 1-844-481-8821. 

You may enroll in the UnitedHealthcare Retiree Advantage Plan if:

• You are enrolled in this UnitedHealthcare FEHBP plan and have both Medicare Part A and Part B
• You are retired and live in our geographic service area. See page (Applies to printed brochure only) for a description of our service area.
• You are a United States citizen or are lawfully present in the United States
• You do NOT have End-Stage Renal Disease (ESRD), with limited exceptions
• You complete an application for enrollment in the UnitedHealthcare Retiree Advantage Plan.

As part of this process CMS will verify your Medicare Part B enrollment. If the FEHB subscriber and or dependent enrolls in the Retiree Advantage plan, each family member will have to complete an application by calling into our Retiree Solutions team (1-844-481-8821). If you enroll in the Retiree Advantage Plan do not suspend or terminate your FEHB plan or all benefits will be termed in both FEHB and Retiree Advantage and you will be without any coverage. Members who are not eligible for Medicare Part A and B will remain on this FEHB plan. If, for any reason, you do not meet the enrollment requirements, you will no longer be eligible to participate in the Retiree Advantage plan. Your contributions will end and your regular FEHB benefits will resume. You may be required to repay any reimbursements paid to you in error.

We offer a plan designed:

• To help members with their Medicare Part B premium costs
• To provide access to our national network of providers, (in-network or out-of-network) at the same cost share
• To cover eligible medical benefits with little to no out of pocket costs
• Medicare Part D prescription drug coverage with a low $2,000 out of pocket max

The Retiree Advantage Plan provides monthly reimbursement of $150.00 of your Medicare Part B monthly premium. In addition, we cover benefits, including office visit copayments at ($0), urgent care and emergency care at ($0), plus additional coverage for hearing aids discounts and wellness programs.   See the chart on next page.

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers). However, we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare..

If you enroll in the UnitedHealthcare Retiree Advantage Group Medicare Advantage plan you must retain your FEHB coverage.  Do not suspend your FEHB coverage as this will make you ineligible for the Retiree Advantage plan. The UnitedHealthcare Retiree Advantage plan includes Medicare part D. Your FEHB plan will not coordinate benefits. The UnitedHealthcare Retiree Advantage plan will take over as the primary and only payer.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area. 

Benefit Description: Deductible
Member Cost without Medicare: No plan deductible
Member Cost with Medicare Part B: No plan deductible
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: No plan deductible

Benefit Description: Out-of-Pocket Maximum
Member Cost without Medicare: $5,000 Self Only, $10,000 Self Plus One, and $10,000 Self and Family
Member Cost with Medicare Part B: $5,000 Self Only, $10,000 Self Plus One, and $10,000 Self and Family
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: You pay nothing for Medicare-covered service from any provider

Benefit Description: Primary Care Physician
Member Cost without Medicare: $25 per visit
Member Cost with Medicare Part B: $25 per visit
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Specialist
Member Cost without Medicare: $35 per visit
Member Cost with Medicare Part B: $35 per visit
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Virtual Visits
Member Cost without Medicare: $0 per visit
Member Cost with Medicare Part B: $5 per visit
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Urgent Care
Member Cost without Medicare: $35 per visit
Member Cost with Medicare Part B: $35 per visit
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Emergency
Member Cost without Medicare: $350 per visit (waived if admitted)
Member Cost with Medicare Part B: $250 per visit (waived if admitted)
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Inpatient Hospital
Member Cost without Medicare: $150 per day (up to $750 per admission)
Member Cost with Medicare Part B: $150 per day (up to $750 per admission)
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Outpatient Hospital
Member Cost without Medicare: Freestanding: $150, Hospital-based: $300
Member Cost with Medicare Part B: Freestanding: $150, Hospital-based: $300
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Rx - (30-day at retail)
Member Cost without Medicare: Tier 1-$10, Tier 2-$50, Tier 3-$100, Tier 4-$200
Member Cost with Medicare Part B: Tier 1-$10, Tier 2-$50, Tier 3-$100, Tier 4–$200
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: Tier 1-$5, Tier 2-$25, Tier 3-$60, Tier 4–$90

Benefit Description: Rx – Mail Order (90-day supply)
Member Cost without Medicare: 2.5 x retail copay
Member Cost with Medicare Part B: 2.5 x retail copay
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: 2 x retail copay

Your FEHB plan will not coordinate benefits with the Retiree Advantage plan. The UnitedHealthcare Retiree Advantage plan will take over as the primary and only payer.

When we are the primary payor, we process the claim first. If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan. If you elect to enroll in the UnitedHealthcare Retiree Advantage plan which includes Medicare part D, your FEHB plan will not coordinate benefits. The UnitedHealthcare Retiree Advantage plan will take over as the primary and only payer.

• You have FEHB coverage on your own or through your spouse who is also an active employee

• You have FEHB coverage through your spouse who is an annuitant

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

• This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

• Medicare based on ESRD (for the 30-month coordination period)

• Medicare based on ESRD (after the 30-month coordination period)

An authorization by you (the enrollee or covered family member) that is approved by us (the Carrier), for us to issue payment of benefits directly to the provider.

• We reserve the right to pay you directly for all covered services. Benefits payable under the contract are not assignable by you to any person without express written approval from us, and in the absence of such approval, any assignment shall be void.
• Your specific written consent for a designated authorized representative to act on your behalf to request reconsideration of a claim decision (or, for an urgent care claim, for a representative to act on your behalf without designation) does not constitute an Assignment.
• OPM’s contract with us, based on federal statute and regulation, gives you a right to seek judicial review of OPM's final action on the denial of a health benefits claim but it does not provide you with authority to assign your right to file such a lawsuit to any other person or entity. Any agreement you enter into with another person or entity (such as a provider, or other individual or entity) authorizing that person or entity to bring a lawsuit against OPM, whether or not acting on your behalf, does not constitute an Assignment, is not a valid authorization under this contract, and is void.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.  Routine care costs- costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's cancer, whether the patient is in a clinical trial or is receiving standard therapy

• Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care.
• Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes.

See Section 4, page (Applies to printed brochure only)

See Section 4, page (Applies to printed brochure only)

See Section 4, page (Applies to printed brochure only)

See Section 4, page (Applies to printed brochure only)

Experimental or Investigational Service(s) - medical, surgical, diagnostic, psychiatric, mental health, substance use disorders or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications or devices that, at the time we make a determination regarding coverage in a particular case are determined to be any of the following:

• Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States American Hospital Pharmacopoeia Dispensing Information as appropriate for the proposed use
• Not recognized, in accordance with generally accepted medical standards, as being safe and effective for your condition;
• Subject to review and approval by any institution review board for the proposed use. (Devices which are FDA approved under the Humanitarian Use Device exemption are not considered to be
  Experimental or Investigational).
• The subject of an ongoing clinical trial that meets the definition of a  Phase 1, 2 or 3 clinical trial set forth in the  FDA regulations, regardless of whether the trial is actually subject to FDA oversight

A physician or other healthcare professional licensed, accredited, or certified to perform specified health services consistent with state law.

A disease (an interruption, cessation, or disorder of body functions, systems, or organs) of the reproductive tract which prevents the conception of a child or the ability to carry a pregnancy to delivery.  It is defined by the failure to achieve a successful pregnancy after 12 months or more of unprotected intercourse or artificial insemination for individuals under age 35.  Earlier evaluation and treatment for those individuals actively looking to achieve a conception may be justified based on medical history and diagnostic testing and is warranted after six (6) months for individuals aged 35 years or older.

Health care services provided for the purpose of preventing, evaluating, diagnosing or treating a sickness, injury, mental illness, substance use disorder disease or its symptoms, that are all of the following as determined by us or our designee, within our discretion.

• In accordance with Generally Accepted Standards of Medical Practice.
• Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your sickness, injury, mental illness, substance use disorder, disease or its symptoms.
• Not mainly for your convenience or that of your doctor or other health care provider
• Not more costly than an alternate drug, service(s) or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your sickness, injury, disease or symptoms.

Generally Accepted Standards of Medical Practice are standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, relying primarily on controlled clinical trials, or if not available, observational studies from more than one institution that suggest a causal relationship between the service or treatment and health outcomes. The fact that a  Physician may prescribe, authorize or direct a service does not of itself make it Medically Necessary or covered by this Plan.

If no credible scientific evidence is available then standards are based on Physician specialty society recommendations or professional standards of care may be considered. We reserve the right to consult expert opinion in determining whether health care services are Medically Necessary. 

Allowable Expense (plan allowance) is a health care expense, including deductibles, coinsurance and copayments, that is covered at least in part by any Plan covering the person. When a Plan provides benefits in the form of services, the reasonable cash value of each service will be considered an Allowable Expense and a benefit paid. An expense that is not covered by any Plan covering the person is not an Allowable Expense. In addition, any expense that a provider by law or in accordance with a contractual agreement is prohibited from charging a covered person is not an Allowable Expense

You should also see Important Notice About Surprise Billing – Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act.

An unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services

Unproven services, including medications, that are determined not to be effective for treatment of the medical condition and/or not to have a beneficial effect on health outcomes due to insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published peer-reviewed medical literature.

• Well-conducted randomized controlled trials. (Two or more treatments are compared to each other, and the patient is not allowed to choose which treatment is received.)
• Well-conducted cohort studies from more than one institution. (Patients who receive study treatment are compared to a group of patients who receive standard therapy. The comparison group must be nearly identical to the study treatment group).

We have a process by which we compile and review clinical evidence with respect to certain health services.  From time to time, we issue medical and drug policies that describe the clinical evidence available with respect to specific health care services.  These medical and drug policies are subject to change without prior notice. You can view these policies at www.myuhc.com.

Please note:  If you have a life-threatening Sickness or condition (one that is likely to cause death within one year of the request for treatment ) we may, in our discretion consider an otherwise Unproven Service to be a Covered Health Service for that Sickness or condition.  Prior to such a consideration, we must first establish that there is sufficient evidence to conclude that, albeit unproven, the service has significant potential as an effective treatment for that Sickness or condition.

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve Pre-Service claims and not Post-Service claims. We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 1-877-835-9861. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

No copayments for preventive care services. This includes items such as, but not limited to, immunizations, physical
examinations and screenings as appropriate and recommended by U.S. Preventive Services Task Force. Please refer to Section 5.

28

$25 per primary care provider (PCP) visit for ages 18 and older, $0 for children under 18 visits to PCP

$35 per specialist visit

25

$35 copayment per visit 

53

$50 per outpatient non-surgical visit

49

$150 per outpatient surgical visit for services performed at approved free standing surgical facility
$300 per outpatient hospital surgical visit

49

$150 per day up to 5 days per admission

48

$350 per emergency room visit (waived if admitted)

51

Regular cost-sharing

53

Tier 1: $10    

Tier 2: $50    

Tier 3: $100

Tier 4: $200

58

Tier 1: $25    

Tier 2: $125    

Tier 3: $250

Tier 4: $500

58

Tier 1 $10

Tier 2 $150

Tier 3 $350

Tier 4 $500

(Applies to printed brochure only)

$35 specialist copayment for eye refraction exam every other year for adults

34

 UnitedHealthcare mobile app, Smoking cessation program, Maternity Health Solutions, Orthopedic Health Support UnitedHealth Premium, Real Appeal, UHC Rewards and One Pass, Specialty Pharmacy, Flexible Benefits Option, Cancer Clinical Trials

(Applies to printed brochure only)

Nothing after $5,000 for Self Only enrollment or $10,000 for Self Plus One and Self and Family enrollment per year. Some costs do not count toward this protection

20

PPO Preventive dental plan at no charge to all members; Resoures for hearing aids and other financial options available for our members

(Applies to printed brochure only)