Minimum essential coverage ( MEC)

Coverage under this plan qualifies as minimum essential coverage (MEC). 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.

Where you can get information about enrolling in the FEHB Program

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 that 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, and give you a brochures for other plans 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 don’t 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.

Types of coverage available for you and your family

Self Only coverage is for you alone. Self Plus One coverage is for you and one eligible family member.  Self and Family coverage is for you, and one eligible family member, or 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.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26.

If you or one of your family members is enrolled in one FEHB plan, you are they cannot be enrolled in or covered as a family member 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 member coverage

Family members covered under your Self and Family enrollment are your spouse (including your spouse by valid common-law marriage if you reside in 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 in the chart 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.

Children’s Equity Act

OPM has implemented 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, 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.

When benefits and premiums start

The benefits in this brochure are effective 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 2021 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 2020 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 FEHB coverage ends

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 31^st 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 60^th 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.)

Upon divorce

If you are divorced from a Federal employee, or annuitant, you may not continue to get benefits 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 vist OPM's website at  www.opm.gov/healthcare-insurance/healthcare/plan-information.  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.

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). The Patient Protection and Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules. 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, if you are a covered dependent child and you turn 26, etc.

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 new kind of 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.

We also want to inform you that the Patient Protection and Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules.

Converting to individual coverage

You may convert to a non-FEHB individual policy if:

• Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);

• You decided not to receive coverage under TCC or the spouse equity law; or

• You are not eligible for coverage under TCC or the spouse equity law.

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 in your state. For assistance in finding coverage, please contact us at 1-866-546-0510 or visit our website at www.uhcfeds.com.

Health Insurance Marketplace

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.

Identification cards

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 UnitedHealthcare Insurance Company, Federal 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 website: www.myuhc.com.

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members.  We credential Plan providers according to national standards.

UnitedHealth Tier 1 Premium Designated providers allow you to reduce your out-of-pocket expenses without compromising on quality.  By using Premium Tier 1 physicians, you save on co-payments and coinsurance.  UnitedHealth Premium Tier 1 physicians have received the Premium designation for either Quality and Cost Efficiency or Cost Efficiency and Not Enough Data to assess Quality.   Look for the UnitedHealth Premium Tier 1 Symbol to quickly and easily find these physicians.  You can find the physicians designation quickly and easily on www.myuhc.com or at www.UnitedHealthPremium.com.

UnitedHealth Tier 1 Premium doctors:

• Follow evidence-based guidelines for care
• Are more likely to be aware of the latest research and clinical trials
• May have lower surgery repeat rates

Quality guidelines are based on standards from organizations such as:

• American College of Cardiology
• Ambulatory Care Quality Alliance
• Agency for Healthcare Research and Quality (a division of the U.S. Department of Health & Human Services)

Plan facilities are hospitals and other facilities that we contract with to provide services to our members.  This plan allows you to save money by choosing a lower cost place of service.

A freestanding facility is an outpatient, diagnostic or ambulatory center or independent laboratory which performs services and submits claims as a freestanding entity and not as a hospital. You will have a lower out of pocket expenses when you use a freestanding facility instead of a hospital for outpatient services.  Outpatient services are health services or treatments that do not require an overnight hospital stay. Outpatient care received in a hospital will typically cost you more. Talk to your doctor about the options available to you for these services.  

Primary care

Your visits to your primary care physician ( PCP) are paid at 100% for all ages and all visits whether they are for preventive care or treatment for an illness.  Your primary care physician may be a family practitioner, an internist or pediatrician.  Your primary care physician will provide most of your health care. 

Specialty care

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 contact your PCP who will assist you in locating an appropriate provider.

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 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. 

• Other services

For certain services,your physician must obtain prior approval from us.  Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.  Your physician must obtain precertification for some services, such as, but not limited to the following services:

• Angioma/Hemangioma (with pictures)
• Applied Behavioral Analysis
• Ambulance (non emergency or air)
• Blepharoplastic (with pictures)
• Breast implant removal, breast reconstruction for non-cancer diagnosis, breast reduction
• Certain out of network services
• Dental procedures in a facility
• Certain Durable Medical Equipment supplies over $1000
• Clinical trials
• Coronary artery bypass graft
• Congenital anomaly repair
• Computed Tomography (CT) scans (brain, chest, heart
• Dialysis
• Discetomy/fusion
• Genetic testing 
• Gynecomastia surgery
• Human Growth hormone
• Hysterectomy
• Infertility services
• Implanted spinal cord stimulators
• Inpatient hospitalization
• Intensive Outpatient Treatment
• Joint replacement
• Morbid obesity surgery
• Magnetic resonance imaging (MRI) (brain, chest, heart, musculoskeletal)
• Magnetic resonance angiogram (MRA)
• Partial Hospitalization
• PET scans (non-cancer diagnosis)
• Pulmonary rehabilitation
• Radiation therapy
• Reconstructive surgery
• Sclerotherapy
• Sleep apnea (surgery & appliance) with sleep studies,(polysomnography) attended
• Transplants
• Therapeutic services: such as physical therapy, occupational therapy and speech therapy after the 8th visit
• Uvulopalatopharyngoplasty
• Vein Ablation
• Ventricular assist device

Call 1-877-835-9861 and they will assist you in determining if your service requires preauthorization.  In addition, your admitting physician and facility must also preauthorize any elective inpatient stays.

How to request precertification for an admission or get prior authorization for other services

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.  Please note that members with Medicare as primary are also required to follow the precertification process.

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 days requested for hospital stay

Non-urgent care claims

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.

Urgent care claims

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).

Concurrent care claims

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

The Federal Flexible Spending Account Program – FSAFEDS

• Health Care FSA (HCFSA) – Reimburses you for eligible out-of-pocket health care expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including 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.

Emergency inpatient admission

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. 

Prior authorization is required if inpatient stay exceeds 48 hours following normal vaginal delivery or 96 hours following a cesarean section delivery.

If your treatment needs to be extended

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.

What happens when you do not follow the precertification rules when using non-network facilities

If you fail to obtain authorization/precertification when using non-network facilities you can be responsible for 100% of the charges.

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.

To reconsider a non-urgent 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. 

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 health care 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.

To reconsider an urgent care claim

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. 

Unless we request 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.

To file an appeal with OPM

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

• Deductible

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible.

• The calendar year deductible is $500 Self Only and $1,000 Self Plus One or Self and Family in-network.  Out-of-network deductible is $3,000 Self Only enrollment, $6,000 Self Plus One or Self and Family.  Under a Self Only enrollment, the in-network deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $500. Under a Self Plus One enrollment, the in-network deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $1,000. Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $1,000.
• There are benefits that are paid prior to your deductible being satisfied, such as Primary Care Visits, Specialist Visits, Virtual/Telemedicine Visits - refer to the benefits section of this brochure for details.
• Note: If you change plans during open season, you do not have to start a new deductible under your old plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.
• We also have a separate deductible for Tier 3 and Tier 4 drugs.  $250 Self Only/$500 Self Plus One or Self and Family

Note: If you change plans during Open Season, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan.  If you change plans at another time during the year, you must begin a new deductible under your new plan.

If you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your prior option to the deductible of your new option. 

Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn’t begin until you meet your deductible.

Differences between our Plan allowance and the bill

Network providers agree to accept our Plan allowance so if you use a network provider, you never have to worry about paying the difference between our Plan allowance and the billed amount for covered services.

Non-network Providers:  If you use a non-network provider, you will have to pay the difference between our Plan allowance and the billed amount.

By using Premium Designated providers in the UnitedHealthcare network, you can take advantage of the significant discounts we have negotiated to help lower your out-of-pocket costs for medically necessary care.  This can help you get the care you need at a lower price.

The example below is based on following the UnitedHealthcare benefits and insurance plan features and assumes that you have already met your deductible.

What your plan pays: (plan coinsurance): 80% in network/60% out of network for benefits with coinsurance.

What you pay (coinsurance): 20% in network/40% out of network.

There are in network benefits that require a copayment only

Your catastrophic protection out-of-pocket maximum

After your in-network out-of-pocket expenses, including any applicable deductibles, copayments and coinsurance total $7,350 for Self Only, or $14,700 for a Self Plus One or Self and Family enrollment in any calendar year, or out-of network $15,000 per Self Only or $30,000 for Self Plus One or Self and Family you do not have to pay any more for covered services.

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:

• Expenses for services and supplies that exceed the stated maximum dollar limit or day limit.

Be sure to keep accurate records and receipts of your copayments and coinsurance to ensure the plan’s calculation of your out-of-pocket maximum is reflected accurately.

Carryover

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 old 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.

Medical Services provided by physicians: Diagnostic and treatment services provided in the office

Primary care physician - zero copayment all ages (Not subject to deductible)

Specialist: $60 copayment in network; Out of network: 40% after deductible has been met and any difference between our allowance and the billed amount 

Medical Services provided by physicians: Routine Preventive Care provided in network

Nothing

Services provided by a hospital: Outpatient Surgical

In-network: 20% coinsurance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Services provided by a hospital: Inpatient

In-network: 20% coinsurance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount 

Emergency benefits: Ambulance - emergency services

In-network: 20% coinsurance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Emergency benefits: Emergency Room

In-network :  20% coinsurance;

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Mental Health and Substance Use Disorder Treatment

Regular cost sharing

Prescription drugs:

Retail 30-day supply:

Tier 1 - $5

Tier 2 - $50

Tier 3 - $100

Tier 4 - 150

Mail-Order 90-day supply:

Tier 1 - $12.50

Tier 2 - $125

Tier 3 - $250

Tier 4 - $375

Note: Tier 3 and Tier 4 drugs are subject to a pharmacy deductible of $250 Self Only/$500 Self Plus One or Self and Family

Medical and hospital benefits

In most cases, providers and facilities file claims for you.  Providers 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, contact 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 domestic medical  claims to: 

UnitedHealthcare, P.O. Box 740817, Atlanta, GA 30374-0817.

Submit international medical claims to:

UnitedHealthcare, PO Box, 740817, Atlanta GA 30374-0817.

Submit your claims to:

Usually, there are no claim forms to fill out when you fill a prescription at a Plan pharmacy.  In some cases, however you may pay out-of-pocket, in an emergency medical situation.  If this happens, send the following information:

• Your receipt
• The drug NDC number
• The pharmacy's NABP number
• The prescribing physician's or dentist's DEA number

Submit your claims to: OptumRx at PO Box 29044, Hot Springs, AR 71903.

Post-service claims procedures

We will notify you of our decision within 30-days after we receive your post-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 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.

Notice Requirements

If you live in a county where at least 10 percent 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 health care provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes

1

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 Benefit Program (FEHB) 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) Include your email address (optional for member), if you would like to receive our decision via email.  Please note that by giving us your email, we may be able to provide 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.

2

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.

3

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, Healthcare and Insurance, 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 health care 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 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  file a lawsuit, 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 file a lawsuit 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 health care 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 coordinating of benefits, visit our website at www.myuhc.com.

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will determine our allowance.  After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit.  We will not pay more than our allowance.   

TRICARE is the health care 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.

Workers' Compensation

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.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.

Medicaid

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 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

When other Government agencies are responsible for your care

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

 Our right to pursue and receive subrogation and reimbursement recoveries is a condition of, and a limitation on, the nature of benefits or benefit payments and on the provision of benefits under our coverage.

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.

If you do pursue a claim or case related to your injury or illness, you must promptly notify us and cooperate with our reimbursement or subrogation efforts.

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage

Some FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental 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 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.

Clinical Trials

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, this health plan will provide related care as follows, if it is not provided by the clinical trial:

• 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.
• 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.  These costs are generally covered by the clinical trials. This plan does not cover these costs.

• The Original Medicare Plan (Part A or Part B)

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.  To find out if you need to do something to file your claim, call us at 1-877-835-9861 or see our member website at www.myuhc.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.

Medicare

Benefit Description: Deductible
High Option - You pay without Medicare - In Network: $500 Self Only; $1,000 Self Plus One or Self and Family
High Option - You pay with Medicare Part B - In Network: $500 Self only; $1,000 Self Plus One or Self and Family

Benefit Description: Out-of-Pocket Maximum
High Option - You pay without Medicare - In Network: $3,000 Self Only/$6,000 Self Plus One or Self and Family
High Option - You pay with Medicare Part B - In Network: $3,000 self only/$6,000 Self Plus One or Self and Family

Benefit Description: Part B Premium Reimbursement
High Option - You pay without Medicare - In Network: N/A
High Option - You pay with Medicare Part B - In Network: N/A

Benefit Description: Primary Care Physician
High Option - You pay without Medicare - In Network: Nothing - Not subject to deductible
High Option - You pay with Medicare Part B - In Network: Nothing - Not subject to deductible

Benefit Description: Specialist
High Option - You pay without Medicare - In Network: $60 copayment - Not subject to deductible
High Option - You pay with Medicare Part B - In Network: $60 copayment - Not subject to deductible

Benefit Description: Inpatient Hospital
High Option - You pay without Medicare - In Network: 20% after deductible
High Option - You pay with Medicare Part B - In Network: 20% after deductible

Benefit Description: Outpatient Hospital
High Option - You pay without Medicare - In Network: 20% after deductible
High Option - You pay with Medicare Part B - In Network: 20% after deductible

Benefit Description: Incentive Offered
High Option - You pay without Medicare - In Network: N/A
High Option - You pay with Medicare Part B - In Network: N/A

• Tell us about your Medicare coverage

• Medicare Part B Premium Reimbursement

We offer a plan designed to help members with their Medicare Part B premiums. This plan is called, UnitedHealthcare Retiree Advantage (UHCA). If you have Medicare Parts A and B and enroll in the UHCA, you will be reimbursed $144.60 of your Medicare Part B monthly premium. This will be sent from Centers for Medicare & Medicaid Services (CMS) directly to your Social Security. If you do not receive a Social Security payment please advise us at enrollment to allow us to make alternative arrangements.

To learn more about UHCA and how to enroll, call us at 1-844-481-8821, 8 a.m. to 8 p.m., local time Monday thru Friday,  For TTY for the deaf, hard of hearing, or speech impaired, call 711. We will send you additional information and an application for enrollment.

• Medicare Advantage (Part C)

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 health care 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, 1-800-633-4227, TTY 1-877-486-2048 or at www.medicare.gov  or  UnitedHealthcare Retiree Services at 1-844-481-8821.

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

This Plan and our Medicare Advantage plan: You may enroll in our Medicare Advantage plan and also remain enrolled in our FEHB plan. 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 13 which describes 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 (UHCA).

Reimbursements will begin on the first of the month following approval of your UHCA application. As part of this process CMS will verify your Medicare Part B enrollment. During a calendar year, you may enroll in UHCA only once. If the FEHB subscriber and/or dependent enrolls in the UHCA, each family member will have to complete an application by calling into our Retiree Services team (1-844-481-8821). Members who are not eligible for Medicare Part A and B will remain on the FEHB plan. If, for any reason, you do not meet the enrollment requirements, you will no longer be eligible to participate in the UHCA 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. Note: If you enroll in our Retiree Advantage plan do not suspend or terminate your FEHB benefits or you will lose all coverage including the FEHB and the Retiree Advantage plan.

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
• To provide coverage with a catastrophic benefits for prescriptions

The UHCA provides monthly reimbursement of $144.60 of your Medicare Part B monthly premium. CMS will process reimbursement directly to your Social Security each month you are covered in the UHCA plan.  If you do not receive a Social Security check please advise us at enrollment to allow us to make alternative arrangements.  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 chart on next page.

Benefit Description: Deductible
Member Cost without Medicare (In Network): $500 Self Only; $1,000 Self Plus One and $1,000 Self and Family
Member Cost with Medicare Part B (In Network): $500 Self Only; $1,000 Self Plus One and $1,000 Self and Family
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: No plan deductible

Benefit Description: Out-of-Pocket Maximum
Member Cost without Medicare (In Network): $7,350 Self Only; $14,700 Self Plus One and $14,700 Self and Family
Member Cost with Medicare Part B (In Network): $7,350 Self Only; $14,700 Self Plus One and $14,700 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 (In Network): $0
Member Cost with Medicare Part B (In Network): $0
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Specialist
Member Cost without Medicare (In Network): $60 per visit
Member Cost with Medicare Part B (In Network): $60  per visit
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Virtual Visits
Member Cost without Medicare (In Network): $0
Member Cost with Medicare Part B (In Network): $0
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Urgent Care
Member Cost without Medicare (In Network): $50 per visit
Member Cost with Medicare Part B (In Network): $50 per visit
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Emergency
Member Cost without Medicare (In Network): 20% after deductible
Member Cost with Medicare Part B (In Network): 20% after deductible
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Inpatient Hospital
Member Cost without Medicare (In Network): 20% after deductible
Member Cost with Medicare Part B (In Network): 20% after deductible
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Outpatient Hospital
Member Cost without Medicare (In Network): $250 copayment after deductible
Member Cost with Medicare Part B (In Network): $250 copayment after deductible
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Rx
Member Cost without Medicare (In Network): Deductible- Tier* (3 & 4 only): $250 Self Only; $500 Self Plus One and Self and Family;  Tier 1-$5; Tier 2-$50; Tier 3-$100*; Tier 4-$150*
Member Cost with Medicare Part B (In Network): Deductible- Tier* (3 & 4 only): $250 Self Only; $500 Self Plus One and Self and Family;  Tier 1-$5; Tier 2-$50; Tier 3-$100*; Tier 4–$150*
Member Cost with UnitedHealthcare Retiree Advantage Health Plan: Tier 1-$7; Tier 2-$35; Tier 3-$65; Tier 4-$100

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

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.

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 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.

• Medicare prescription drug coverage (Part D)

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. 

Clinical trials cost categories

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. These costs are generally covered by the clinical trials. This plan does not cover these costs.

Coinsurance

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

Copayment

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

Cost Sharing

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

Deductible

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.

Medical necessity

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. 

Plan allowance

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.

Unproven Service(s)

Unproven services, including medications, are services 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.

Urgent care claims

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.

Medical services provided by physicians: Diagnostic and treatment services provided in the office

In-network: Primary care physician (PCP) You pay nothing - not subject to deductible

Out-of-network: Primary care physician (PCP) You pay nothing - not subject to deductible 

Specialist:

$60 copayment - not subject to deductible 

* Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount 

28

Medical services provided by physicians: Telehealth services/Virtual visits

In-network - you pay nothing - Not subject to deductible

* Out-of-Network - 40% of the Plan allowance and any difference between our allowance and the billed amount 

28

Services provided by a hospital: Inpatient*

In-network: 20% coinsurance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

(Applies to printed brochure only)

Services provided by a hospital: Outpatient (Non-surgical)*

In-network: 20% coinsurance

Out-of-network: 40% of the plan allowance and any difference between our allowance and the billed amount 

(Applies to printed brochure only)

Emergency benefits: Emergency Room of Hospital

20% coinsurance per visit in-network *

40% of the Plan allowance and any difference between our allowance and the billed amount or out-of-network *

(waived if admitted)

54

Emergency benefits: Urgent Care Facility

In-network: $50 copayment per visit - not subject to deductible

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount - subject to deductible

(Applies to printed brochure only)

Mental health and substance use disorder treatment *:

Regular cost sharing

(Applies to printed brochure only)

Prescription drugs: Retail pharmacy

Up to 30-day supply at retail 

Tier 1: $5 copayment

Tier 2: $50 copayment

Tier 3: $100 copayment

Tier 4: $150 copayment

Subject to pharmacy deductible for Tier 3 and Tier 4. See "Deductible" below

(Applies to printed brochure only)

Prescription drugs: Mail order

Up to 90-days at Plan Mail Order (in-network only)

Tier 1: $12.50 copayment

Tier 2: $125 copayment

Tier 3: $250 copayment

Tier 4: $375  copayment

Subject to pharmacy deductible for Tier 3 and Tier 4. See "Deductible" below.

(Applies to printed brochure only)

Vision care:

Routine eye examination for children as described in the Bright Future Guidelines is covered at 100%

In-network: 20% coinsurance *

Out-of-Network: 40% of the Plan allowance and any difference between our allowance and the billed amount  *

35

Annual Deductible

In-network

• $500 Self Only, $1,000 Self Plus One and Self and Family

Out-of-network:

• $3,000 Self Only, $6,000 Self Plus One and Self and Family

Pharmacy:

• Applies only to Tier 3 and Tier 4, $250 Self Only; $500 Self Plus One and Self and Family

21

Protection against catastrophic costs (out-of-pocket maximum):

You pay nothing after:

In-network:

• $7,350 Self Only
• $14,700 Self plus One and Self and Family

Out-of-Network:

• $15,000   Self Only
• $30,000   Self Plus One and Self and Family

21

Wellness and Other Special features

UnitedHealthcare mobile app, Quit for Life, Maternity Support Program, Spine and Joint Program, UnitedHealth Premium, Real Appeal, Specialty Pharmacy, Flexible Benefits Option, Cancer Clinical Trials,

(Applies to printed brochure only)

Non-FEHB Benefits Available to Plan Members

PPO Dental Plan, UnitedHealthcare Hearing, Rally, SafeTrip and other individual insurance products

(Applies to printed brochure only)