YOUR BENEFITS 10/1/2013 Benefit Summary ASO Choice Plus
Greeneview Local Schools Medical Plan 7ME-M UnitedHealthcare and EPC want to help you take control and make the most of your health care benefits. That’s why we provide convenient services to get your health care questions answered quickly and accurately: • myuhc.com® - Take advantage of easy, time-saving online tools. You can check your eligibility, benefits, claims, claim payments, search for a doctor and hospital and much, much more. 24-hour nurse support – A nurse is a phone call away and you have other health resources available 24-hours a day, 7 days a week to provide you with information that can help you make informed decisions. Just call the number on the back of your ID card. Customer Care telephone support – Need more help? Call a customer care professional using the toll-free number on the back of your ID card. Get answers to your benefit questions or receive help looking for a doctor or hospital.
The Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine your coverage. If this Benefit Summary conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
Member Copayments do not accumulate towards the Deductible
Out-of-Pocket Maximum Individual Out-of-Pocket Maximum
The Out-of-Pocket Maximum includes the Annual Deductible.
Member Copayments do not accumulate towards the Out-of-Pocket Maximum.
Benefit Plan Coinsurance – The Amount the Plan Pays
80% after Deductible has been met for most services
70% after Deductible has been met for most services
Lifetime Maximum Benefit The maximum amount the Plan will pay during
the entire period of time you are enrolled under the Plan
Prescription drug benefits are shown under separate cover.
Information of Pre-service Notification *Pre-service Notification is required for certain services. **Pre-service Notification is required for Equipment in excess of $1,000 both in and out of network. Information on Benefit Limits
The Annual Deductible, Out-of-Pocket Maximum and Benefit limits are calculated on a calendar year basis.
All Benefits are reimbursed based on Eligible Expenses. For a definition of Eligible Expenses, please refer to your Summary Plan Description.
When Benefit limits apply, the limit refers to any combination of Network and Non-Network Benefits unless specifically stated in the Benefit category.BENEFITS
Ambulance Services – Emergency and Non-Emergency
* 80% after Network Deductible has been met
Dental Services – Accident Only Benefits are limited as follows:
* 80% after Network Deductible has been met
$900 maximum per tooth Durable Medical Equipment (DME) Benefits are limited as follows:
Benefits are limited to a single purchase of a
type of Durable Medical Equipment (including
repair and replacement) every three years.
THIS MATERIAL IS PROVIDED ON THE RECIPIENT’S AGREEMENT THAT IT WILL ONLY BE USED FOR THE PURPOSE OF DESCRIBING UNITEDHEALTHCARE’S PRODUCTS AND
SERVICES TO THE RECIPIENT. ANY OTHER USE, COPYING OR DISTRIBUTION WITHOUT THE EXPRESS WRITTEN PERMISSION OF UNITEDHEALTHCARE IS PROHIBITED.
100% after you pay a $100 Copayment per visit. If
* 100% after you pay a $100 Copayment per
you are admitted as an inpatient to a Network
Hospital directly from the Emergency room, you
will not have to pay this Copayment. The Benefits
for an Inpatient Stay in a Network Hospital will
Home Health Care Benefits are limited as follows:
Lab, X-Ray and Diagnostics - Outpatient For Preventive Lab, X-Ray and Diagnostics, refer
to the Preventive Care Services category.
Lab, X-Ray and Major Diagnostics – CT, PET, MRI and Nuclear Medicine - Outpatient
Mental Health and Substance Abuse Services – Inpatient and Intermediate
* 100% after you pay a $250 Copayment per
Mental Health and Substance Abuse Services – Outpatient
* 100% after you pay a $20 Copayment per visit
Physician Fees for Surgical and Medical Services
Physician’s Office Services – Sickness and Injury Primary Physician Office Visit
100% after you pay a $20 Copayment per visit
100% after you pay a $20 Copayment per visit
No copayment applies if physician’s charge is not assessed. In addition to the visit Copayment, the applicable Copayment and any Deductible/Coinsurance applies when these services are done: Pharrmaceutical Products Pregnancy – Maternity Services
Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each covered Health Service category in this Benefit Summary For services provided in the Physician’s Office, a Copayment will only
Pre-service Notification is required if Inpatient Stay exceeds 48 hours following a normal vaginal delivery or 96 hours following a cesarean section delivery.
Preventive Care Services Covered Health Services include but are not
limited to: Primary Physician Office Visit
Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this Benefit Summary
Pre-service Notification is required for certain services.
Rehabilitation Services – Outpatient Therapy and Chiropractic Treatment Benefits are limited as follows:
100% after you pay a $20 Copayment per visit
Network and Non-Network benefits are limited to
a combined total of 50 visits per calendar year for
Occupational therapy Speech therapy Pulmonary rehabilitation Cardiac rehabilitation Post-Cochlear implant aural therapy Vision therapy Scopic Procedures – Outpatient Diagnostic and Therapeutic Diagnostic scopic procedures include, but are not
Endoscopy For Preventive Scopic Procedures, refer to the Preventive Care Services category. Skilled Nursing Facility / Inpatient Rehabilitation Facility Services Benefits are limited as follows:
For Network Benefits, services must be received at
100% after you pay a $35 Copayment per visit
In addition to the visit Copayment, the applicable Copayment and any Deductible/Coinsurance applies when these services are done: Pharrmaceutical Products Vision Examinations Benefits are limited as follows:
100% after you pay a $20 Copayment per visit
It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
Acupressure; aromatherapy; hypnotism; massage therapy; rolfing (holistic tissue massage); art, music, dance, horseback therapy; and other forms of alternative treatment as defined by the National Center for
Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health. This exclusion does not apply to Chiropractic Treatment and osteopathic care for which Benefits are provided as described in the
Dental care (which includes dental X-rays, supplies and appliances and all associated expenses, including hospitalizations and anesthesia). This exclusion does not apply to dental care (oral examination, X-rays,
extractions and non-surgical elimination of oral infection) required for the direct treatment of a medical condition for which Benefits are available under the Plan as described in the SPD. Dental care that is required to
treat the ef ects of a medical condition, but that is not necessary to directly treat the medical condition, is excluded. Examples include treatment of dental caries resulting from dry mouth after radiation treatment or as a
result of medication. Endodontics, periodontal surgery and restorative treatment are excluded. Diagnosis or treatment of or related to the teeth, jawbones or gums. Examples include: extraction (including wisdom teeth),
restoration, and replacement of teeth; medical or surgical treatment of dental conditions; and services to improve dental clinical outcomes. This exclusion does not apply to accidental-related dental services for which
Benefits are provided as described under Dental Services – Accidental Only in the SPD. Dental implants, bone grafts and other implant-related procedures. This exclusion does not apply to accident-related dental
services for which Benefits are provided as described under Dental Services – Accident Only in the SPD. Dental braces (orthodontics). Congenital Anomaly such as cleft lip or cleft palate.
Devices used specifically as safety items or to af ect performance in sports-related activities. Orthotic appliances that straighten or re-shape a body part. Examples include foot orthotics, cranial banding and some types
of braces, including over-the-counter orthotic braces. The following items are excluded, even if prescribed by a Physician: blood pressure cuff/monitor; enuresis alarm; home coagulation testing equipment; non-wearable
external defibril ator; trusses; ultrasonic nebulizers; and ventricular assist devices. Devices and computers to assist in communication and speech except for speech aid prosthetics and tracheo-esophogeal voice
prosthetics. Oral appliances for snoring. Repair and replacement prosthetic devices when damaged due to misuse, malicious damage or gross neglect. Prosthetic devices. This exclusion does not apply to breast
prosthesis, mastectomy bras and lymphedema stockings for which Benefits are provided as described under Reconstructive Procedures in the SPD.
The exclusions listed below apply to the medical portion of the Plan only. Prescription Drug coverage is excluded under the medical plan because it is a separate benefit. Coverage may be available under the
Prescription Drug portion of the Plan. See the SPD for coverage details and exclusions.
Prescription drugs for outpatient use that are fil ed by a prescription order or refil . Self-injectable medications. This exclusion does not apply to medications which, due to their characteristics (as determined by
UnitedHealthcare), must typically be administered or directly supervised by a qualified provider or licensed/certified health professional in an outpatient set ing. Non-injectable medications given in a Physician’s of ice.
This exclusion does not apply to non-injectable medications that are required in an Emergency and consumed in the Physician’s office. Over-the-counter drugs and treatments. Growth hormone therapy.
Experimental or Investigational or Unproven Services
Experimental or Investigational or Unproven Services, unless the Plan has agreed to cover them as defined in the SPD. This exclusion applies even if Experimental or Investigational Services or Unproven Services,
treatments, devices or pharmacological regimens are the only available treatment options for your condition. This exclusion does not apply to Covered Health Services provided during a clinical trial for which Benefits are
provided as described under Clinical Trials in the SPD.
Routine foot care. Examples include the cutting or removal of corns and calluses. This exclusion does not apply to preventive foot care for Covered Persons with diabetes for which Benefits are provided as described
under Diabetes Services in the SPD or when needed for severe systemic disease. Cutting or removal of corns and calluses. Nail trimming, cut ing, or debriding. Hygienic and preventive maintenance foot care; and other
services that are performed when there is not a localized Sickness, Injury or symptom involving the foot. Examples include: cleaning and soaking the feet; applying skin creams in order to maintain skin tone. This
exclusion does not apply to preventive foot care for Covered Persons who are at risk of neurological or vascular disease arising from diseases such as diabetes. Treatment of flat feet. Shoes (standard or custom), lifts
and wedges; shoe orthotics; shoe inserts and arch supports
Prescribed or non-prescribed medical supplies and disposable supplies. Examples include: elastic stockings, ace bandages, diabetic strips, and syringes; urinary catheters. This exclusion does not apply to:
Disposable supplies necessary for the effective use of Durable Medical Equipment for which Benefits are provided as described under Durable Medical Equipment in the SPD.
Diabetic supplies for which Benefits are provided as described under Diabetes Services in the SPD.
Ostomy bags and related supplies for which Benefits are provided as described under Ostomy Supplies in the SPD.
Tubings, nasal cannulas, connectors and masks, [except when used with Durable Medical Equipment as described under Durable Medical Equipment as described in the SPD. The repair and replacement of Durable
Medical Equipment when damaged due to misuse, malicious breakage or gross neglect and deodorants, filters, lubricants, tape, appliance clears, adhesive, adhesive remover or other items that are not specifically
Inpatient, intermediate or outpatient care services that were not pre-authorized by the Mental Health/Substance Abuse (MH/SA) Administrator; Services performed in connection with conditions not classified in the
current edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders.
Mental Health Services and Substance Abuse Services that extend beyond the period necessary for short-term evaluation, diagnosis, treatment, or crisis intervention. Mental Health Services as treatment for insomnia
and other sleep disorders, neurological disorders and other disorders with a known physical basis. Treatment for conduct and impulse control disorders, personality disorders, paraphilias (sexual behavior that is
considered deviant or abnormal) and other Mental Il nesses that wil not substantially improve beyond the current level of functioning, or that are not subject to favorable modification or management according to
prevailing national standards of clinical practice, as reasonably determined by the Mental Health/Substance Abuse Administrator. Services utilizing methadone, L.A.A.M. (1-Alpha-Acetyl-Methadol), Cyclazocine, or their
equivalents as maintenance treatment for drug addiction. Treatment provided in connection with involuntary commitments, police detentions and other similar arrangements ,unless authorized by the Mental
Health/Substance Abuse Administrator. Residential treatment services. Routine use of psychological testing without specific authorization; pastoral counseling. Services or supplies for the diagnosis or treatment of
Mental Il ness, alcoholism or substance abuse disorders that, in the reasonable judgment of the Mental Health/Substance Abuse Administrator, typically do not result in outcomes demonstrably bet er than other available
treatment alternatives that are less intensive or more cost effective, or are not consistent with:
Prevailing national standards of clinical practice for the treatment of such conditions.
Prevailing professional research demonstrating that the services or supplies wil have a measurable and beneficial health outcome.
The Mental Health/Substance Abuse Administrator’s level of care guidelines as modified from time to time.
The Mental Health/Substance Abuse Administrator may consult with professional clinical consultants, peer review commit ees or other appropriate sources for recommendations and information regarding whether a
service or supply meets any of these criteria.
MEDICAL EXCLUSIONS Continued
Nutritional or cosmetic therapy using high dose or mega quantities of vitamins, minerals or elements, and other nutrition based therapy. Nutritional counseling for either individuals or groups except as defined under
Nutritional Counseling in the SPD. Food of any kind. Foods that are not covered include: enteral feedings and other nutritional and electrolyte formulas, including infant formula and donor breast milk unless they are the
only source of nutrition or unless they are specifically created to treat inborn errors of metabolism such as phenylketonuria (PKU) – infant formula available over the counter is always excluded; foods to control weight,
treat obesity (including liquid diets), lower cholesterol or control diabetes; oral vitamins and minerals; meals you can order from a menu, for an additional charge, during an Inpatient Stay, and other dietary and electrolyte
supplements; and health education classes unless offered by UnitedHealthcare or its affiliates, including but not limited to asthma, smoking cessation, and weight control classes.
Television; telephone; beauty/barber service; guest service. Supplies, equipment and similar incidental services and supplies for personal comfort. Examples include: air conditioners, air purifiers and filters, dehumidifiers
and humidifiers; batteries and battery chargers; breast pumps; car seats; chairs, bath chairs, feeding chairs, toddler chairs, chair lifts, recliners; electric scooters; exercise equipment and treadmil s; home modifications to
accommodate a health need such as ramps, swimming pools, elevators, handrails and stair glides; hot tubs; Jacuzzis, saunas and whirlpools; ergonomically correct chairs, non-Hospital beds, comfort beds, mattresses;
medical alert systems; motorized beds; music devices; personal computers, pil ows; power-operated vehicles; radios; saunas; strollers; safety equipment; vehicle modifications such as van lifts; and video players.
Cosmetic Procedures. See the definition in the SPD. Examples include: pharmacological regimens, nutritional procedures or treatments; Scar or tattoo removal or revision procedures (such as salabrasion, chemosurgery
and other such skin abrasion procedures); Skin abrasion procedures performed as a treatment for acne; treatment of hair loss; varicose vein treatment of the lower extremities, when it is considered cosmetic; Liposuction
or removal of fat deposits considered undesirable, including fat accumulation under the male breast and nipple; Treatment for skin wrinkles or any treatment to improve the appearance of the skin; Treatment for spider
veins; Hair removal or replacement by any means. Replacement of an existing intact breast implant if the earlier breast implant was performed as a Cosmetic Procedure. Treatment of benign gynecomastia (abnormal
breast enlargement in males). Breast reduction except as coverage is required by the Women’s Health and Cancer Right’s Act of 1998 for which Benefits are described under Reconstructive Procedures in the SPD.
Physical conditioning programs such as athletic training, body-building, exercise, fitness, flexibility, health club memberships and programs, spa treatments and diversion or general motivation. Weight loss programs
whether or not they are under medical supervision. Weight loss programs for medical reasons are also excluded, even if for morbid obesity. Wigs regardless of the reason for the hair loss ,expect for temporary loss of
hair resulting from treatment of a malignancy.
Procedure or surgery to remove fatty tissue such as panniculectomy, abdominoplasty, thighplasty, brachioplasty, or mastopexy. Excision or elimination of hanging skin on any part of the body. Examples include plastic
surgery procedures called abdominoplasty or abdominal panniculectomy, and brachioplasty. Medical and surgical treatment of excessive sweating (hyperhidrosis). Medical and surgical treatment for snoring, except when
provided as a part of treatment for documented obstructive sleep apnea. Speech therapy except as required for treatment of a speech impediment or speech dysfunction that results from Injury, stroke, cancer,
Congenital Anomaly, or autism spectrum disorders. Speech therapy to treat stuttering, stammering or other articulation disorders. Psychosurgery. Sex transformation operations. Physiological modalities and procedures
that result in similar or redundant therapeutic effects when performed on the same body region during the same visit or of ice encounter. Biofeedback. Chiropractic treatment to treat a condition unrelated to spinal
manipulation and ancil ary physiologic treatment rendered to restore/improve motion, reduce pain and improve function, such as asthma or allergies. Chiropractic treatment (the therapeutic application of chiropractic
manipulative treatment with or without ancil ary physiologic treatment and/or rehabilitative methods rendered to restore/improve motion, reduce pain and improve function). Services for the evaluation and treatment of
temporomandibular joint syndrome (TMJ), whether the services are considered to be dental in nature, including oral appliances: surface electromyography; Doppler analysis; vibration analysis; computerized mandibular
scan or jaw tracking; craniosacral therapy; orthodontics; occlusal adjustment; dental restorations. Upper and lower jawbone surgery except as required for direct treatment of acute traumatic Injury, dislocation, tumors or
cancer. Diagnosis or treatment of the jawbones, including Orthognathic surgery, and jaw alignment, except as a treatment of obstructive sleep apnea. Non-surgical treatment of obesity even if for morbid obesity. Surgical
treatment of obesity unless there is a diagnosis of morbid obesity as described under Obesity Surgery in the SPD. Treatment of tobacco dependency. Chelation therapy, except to treat heavy metal poisoning.
Services performed by a provider who is a family member by birth or marriage. Examples include a spouse, brother, sister, parent or child. This includes any service the provider may perform on himself or herself.
Services performed by a provider with your same legal residence. Services ordered or delivered by a Christian Science practitioner. Services performed by an unlicensed provider or a provider who is operating outside of
the scope of his/her license. Services provided at a free-standing or Hospital-based diagnostic facility without an order writ en by a Physician or other provider. Services which are self-directed to a free-standing or
Hospital-based diagnostic facility. Services ordered by a Physician or other provider who is an employee or representative of a free-standing or Hospital-based diagnostic facility, when that Physician or other provider has
not been actively involved in your medical care prior to ordering the service, or is not actively involved in your medical care after the service is received. This exclusion does not apply to mammography. Foreign language
Health services and associated expenses for infertility treatments, including assisted reproductive technology,
regardless of the reason for the treatment. This exclusion does not apply to services required to treat or correct underlying causes of infertility. The following infertility treatment-related services: cryo-preservation and
other forms of preservation of reproductive materials, long-term storage of reproductive materials such as sperm, eggs, embryos, ovarian tissue, and testicular tissue, donor services. Surrogate parenting, donor eggs,
donor sperm and host uterus. Storage and retrieval of all reproductive materials. Examples include eggs, sperm, testicular tissue and ovarian tissue. The reversal of voluntary sterilization. Health services and associated
expenses for elective surgical, non-surgical, or drug-induced Pregnancy termination. This exclusion does not apply to treatment of a molar Pregnancy, ectopic Pregnancy, or missed abortion (commonly known as a
miscarriage). Services provided by a doula (labor aide); and parenting, prenatal or birthing classes. Artificial reproduction treatments done for genetic or eugenic.
Health services for which other coverage is available under another plan, except for Eligible Expenses payable as described in the SPD. Examples include coverage required by workers’ compensation, no-fault auto
insurance, or similar legislation. If coverage under workers’ compensation, no-fault automobile coverage or similar legislation is optional for you because you could elect it, or could have it elected for you. Health services
for treatment of military service-related disabilities, when you are legally entitled to other coverage and facilities are reasonably available to you. Health services while on active military duty.
Health services for organ and tissue transplants, except as identified under Transplantation Services in the SPD. Mechanical or animal organ transplants, except services related to the implant or removal of a circulatory
assist device (a device that supports the heart while the patient waits for a suitable donor heart to become available); and donor costs for organ or tissue transplantation to another person (these contest may be payable
through the recipient’s benefit plan).
Travel or transportation expenses, even if ordered by a Physician, except as identified under Travel and Lodging in the SPD. Additional travel expenses related to Covered Health Services received from a Designated
Facility or Designated Physician may be reimbursed at the Plan’s discretion.
Multi-disciplinary pain management programs provided on an inpatient basis. Custodial care; domiciliary care. Private duty nursing. Respite care; rest cures; services of personal care attendants. Work hardening
(individualized treatment programs designed to return a person to work or to prepare a person for specific work).
Purchase cost and associated fit ing charge for eye glasses and contact lenses. Implantable lenses used only to correct a refractive error (such as Intacs corneal implants). Purchase cost and associated fit ing and
testing charges for hearing aids, Bone Anchor Hearing Aids (BAHA) and all other hearing assistive devices. Eye exercise therapy. Surgery and other related treatment that is intended to correct nearsightedness,
farsightedness, presbyopia and astigmatism including, but not limited to, procedures such as laser and other refractive eye surgery and radial keratotomy.
Health services and supplies that do not meet the definition of a Covered Health Service – see the definition of Covered Health Services in the Glossary in the SPD. Physical, psychiatric or psychological exams, testing,
vaccinations, immunizations or treatments when: required solely for purposes of career, education, school, sports or camp, travel, employment, insurance, marriage or adoption; or as a result of incarceration; related to
judicial or administrative proceedings or orders; conducted for purposes of medical research; required to obtain or maintain a license of any type. Health services received as a result of war or any act of war, whether
declared or undeclared or caused during service in the armed forces of any country. Health services received after the date your coverage under the Plan ends. This applies to all health services, even if the health
service is required to treat a medical condition that arose before the date your coverage under the Plan ended. Health services for which you have no legal responsibility to pay, or for which a charge would not ordinarily
be made in the absence of coverage under the Plan. Charges that exceed Eligible Expenses or any specified limitation in the SPD. Health services when a provider waives the Copay, Annual Deductible or Coinsurance
amounts. Autopsies and other coroner services and transportation services for a corpse. Charges for: missed appointments; room or facility reservations; completion of claim forms; or record processing. Charges
prohibited by federal anti-kickback or self-referral status. Diagnostic tests that are: delivered in other than a Physician’s office or health care facility; and self-administered home diagnostic tests, including but not limited to
HIV and pregnancy tests. Vision therapy when rendered in connection with behavioral health disorders, including but not limited to: learning and reading disabilities; attention deficit/hyperactively disorder; TBI; or dyslexia
YOUR BENEFITS 10/1/2013 Benefit Summary Outpatient Prescription Drug
Greeneview Local Schools Pharmacy Plan 0F5
Your Copayment and/or Coinsurance is determined by the tier to which the Prescription Drug List Management Committee has assigned the Prescription Drug. All Prescription Drugs on the Prescription Drug List are assigned to Tier-1, Tier-2 or Tier-3. Find individualized information on your benefit coverage, determine tier status, check the status of claims and search for network pharmacies by logging on to www.myuhc.com® or calling Customer Care at the telephone number on the back of your ID card
This summary of Benefits is intended only to highlight your Benefits for Prescription Drugs and should not be relied upon to determine coverage. Your plan may not cover all of your Prescription Drug expenses. Please refer to the Prescription Drug section of the Summary Plan Description (SPD) for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. If this description conflicts in any way with the Prescription Drug section of the SPD, the Prescription Drug section of SPD shall prevail.
Annual Drug Deductible – Network and Non-Network Individual Deductible
Out-of-Pocket Drug Maximum – Network and Non-Network Individual Out-of-Pocket Maximum
* Only certain Prescription Drugs are available through mail order; please visit www.myuhc.com® or call Customer Care at the telephone number on the back of your ID card for more information.
An Ancillary Charge may apply when a covered Prescription Drug is dispensed at your [or your provider’s] request and there is another drug that is chemically the same available at a lower tier. When you choose the higher tiered drug of the two, you will pay the difference between the higher tiered drug and the lower tiered drug in addition to your Copayment and/or Coinsurance that applies to the lower tier drug.
Note: If you purchase a Prescription Drug from a Non-Network Pharmacy, you are responsible for any difference between what the Non-Network Pharmacy charges and the amount we would have paid for the same Prescription Drug dispensed by a Network Pharmacy.
THIS MATERIAL IS PROVIDED ON THE RECIPIENT’S AGREEMENT THAT IT WILL ONLY BE USED FOR THE PURPOSE OF
DESCRIBING UNITED HEALTHCARE SERVICES, INC.’S PRODUCTS AND SERVICES TO THE RECIPIENT. ANY OTHER USE, COPYING OR
DISTRIBUTION WITHOUT THE EXPRESS WRITTEN PERMISSION OF UNITED HEALTHCARE SERVICES, INC. IS PROHIBITED.
Other Important Information about your Outpatient Prescription Drug Benefits
You are responsible for paying the lower of the applicable Copayment and/or Coinsurance or the retail Network Pharmacy’s Usual and Customary Charge, or the lower of the applicable Copayment and/or Coinsurance or the mail order Network Pharmacy’s Prescription Drug Cost.
For a single Copayment and/or Coinsurance, you may receive a Prescription Drug up to the stated supply limit. Some Prescription Drugs are subject to additional supply limits
Some Prescription Drug or Pharmaceutical Products for which Benefits are described under the Prescription Drug section of the Summary Plan Description (SPD) are subject to step therapy requirements. This means that in order to receive Benefits for such Prescription Drug or Pharmaceutical Products you are required to use a different Prescription Drug(s) or Pharmaceutical Product(s) first.
Also note that some Prescription Drugs require that you notify us in advance to determine whether the Prescription Drug meets the definition of a Covered Health Service and is not Experimental, Investigational or Unproven.
You may be required to fill an initial Prescription Drug Product order and obtain one refilll through a retail pharmacy prior to using a mail order Network Pharmacy.
Exclusions from coverage listed in the SPD apply also to this Prescription Drug section. In addition, the following exclusions apply: Exclusions
• Coverage for Prescription Drugs for the amount dispensed (days’ supply or quantity limit) which exceeds the supply
• Coverage for Prescription Drug Products for the amount dispensed (days' supply or quantity limit) which is less than the
• Prescription Drugs dispensed outside the United States, except as required for Emergency treatment. • Drugs which are prescribed, dispensed or intended for use during an Inpatient Stay.
• Experimental, Investigational or Unproven Services and medications; medications used for experimental indications
and/or dosage regimens determined to be experimental, investigational or unproven, unless United HealthCare Services, Inc. and the EPC have agreed to cover.
• Prescription Drugs furnished by the local, state or federal government. Any Prescription Drug to the extent payment or
benefits are provided or available from the local, state or federal government (for example, Medicare) whether or not payment or benefits are received, except as otherwise provided by law.
• Prescription Drugs for any condition, Injury, Sickness or mental illness arising out of, or in the course of, employment for
which benefits are available under any workers’ compensation law or other similar laws, whether or not a claim for such benefits is made or payment or benefits are received.
• Any product dispensed for the purpose of appetite suppression or weight loss. • A Pharmaceutical Product for which Benefits are provided in the Summary Plan Description (SPD). This exclusion
does not apply to Depo Provera and other injectable drugs used for contraception.
• Durable Medical Equipment. Prescribed and non-prescribed outpatient supplies, other than the diabetic supplies and
inhaler spacers specifically stated as covered.
• General vitamins, except the following which require a Prescription Order or Refill: prenatal vitamins, vitamins with
• Unit dose packaging of Prescription Drugs.
• Medications used for cosmetic purposes. • Prescription Drugs, including New Prescription Drugs or new dosage forms, that EPC determine do not meet the
• Prescription Drugs as a replacement for a previously dispensed Prescription Drug that was lost, stolen, broken or
• Prescription Drugs when prescribed to treat infertility. • Certain Prescription Drugs for smoking cessation.
• Compounded drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug
Administration and requires a Prescription Order or Refill. Compounded drugs that are available as a similar commercially available Prescription Drug. (Compounded drugs that contain at least one ingredient that requires a Prescription Order or Refill are assigned to Tier 3.
• Drugs available over-the-counter that do not require a Prescription Order or Refill by federal or state law before being
dispensed, unless the Plan Administrator has designated the over-the-counter medication as eligible for coverage as if it were a Prescription Drug and it is obtained with a Prescription Order or Refill from a Physician. Prescription Drugs that are available in over-the-counter form or comprised of components that are available in over-the-counter form or equivalent. Certain Prescription Drugs that the Plan Administrator has determined are Therapeutically Equivalent to an over-the-counter drug. Such determinations may be made up to six times during a calendar year, and the Plan Administrator may decide at any time to reinstate Benefits for a Prescription Drug that was previously excluded under this provision.
• Certain New Prescription Drugs and/or new dosage forms until the date they are reviewed and assigned to a tier by our
Prescription Drug List Management Committee.
• Growth hormone for children with familial short stature (short stature based upon heredity and not caused by a
• A Prescription Drug that contains (an) active ingredient(s) available in and Therapeutically Equivalent to another
• A Prescription Drug that contains (an) active ingredient(s) which is (are) a modified version of and Therapeutically
Equivalent to another covered Prescription Drug.
• A Prescription Drug typically administered by a qualified provider or licensed health professional in an outpatient
setting. This exclusion does not apply to Depo provera and other injectable drugs used for contraception.
• Certain Prescription Drug Products that have not been prescribed by a Specialist Physician.
Drugs & Supplements: Vitamin B12 (Print Version) Vitamin B12 URL of this page: http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-vitaminb12.html Background Vitamin B12 is an essential water soluble vitamin that is commonly found in a variety of foods such as fish, shellfish,meats, and dairy products. Vitamin B12 is frequentl
P.O. Box 43653 Louisville, KY 40253-0653 (502) 244-1161 (800) 919-BMSI FAX (502) 244-1162 www.bmsllc.net ELECTION FORM FOR THE FLEXIBLE BENEFIT PLAN Employer_______________________________________ Employee Name ____________________________________ Social Security # _________________________________ Date of Birth ___________________________________ Mailing Address ________________