UnitedHealthcare Insurance Company Written Plan Description [CHOICE][EXCLUSIVE PROVIDER PLAN] This coverage is provided by UnitedHealthcare Insurance Company (UnitedHealthcare). This coverage provides benefits only when a Preferred Provider (Network Provider) or a Non-Preferred Provider (Non-network Provider) is used, except as otherwise noted. If you have questions or need additional information, you may write to us at our Home Office at UnitedHealthcare Insurance Company 450 Columbus Boulevard Hartford, Connecticut 06115-0450 or you may contact us, toll free, at 1-800-357-1371 A Network Provider is a hospital, physician or other health care provider who has contracted with us for the purpose of reducing health care costs by negotiating fees for services provided to Insured Persons. A non-network Provider is a hospital, physician or other health care provider who has not contracted with us. Please Note: this benefit plan includes limited Benefits for services provided by a Physician or health care provider that is not a Network provider. For a list of Network providers go to www.myuhc.com or call Customer Care at the telephone number on the back of your ID card. Benefits Annual Deductibles are calculated on a [calendar] [Policy] year basis. Out-of-Pocket Maximums are calculated on a [calendar] [Policy] year basis. [When Benefit limits apply, the limit stated includes Covered Health Services provided at a Designated Provider level of Benefits unless otherwise specifically stated.] Benefit limits are calculated on a [calendar] [Policy] year basis unless otherwise specifically stated. WPD.EPO.I.11.TX R1
Benefits for Prescription Drug Products Benefits are available for Prescription Drug Products at a Network Pharmacy and are subject to Copayments and/or Coinsurance or other payments that vary depending on which of the tiers of the Prescription Drug List the Prescription Drug Product is listed. [Benefits are provided only when the Prescription Order or Refill has been issued by a Network Physician or other Network provider.] Benefits for Prescription Drug Products are available when the Prescription Drug Product meets the definition of a Covered Health Service or is prescribed to prevent conception. Supply Limits Benefits for Prescription Drug Products are subject to the supply limits that are stated in the Description and Supply Limits column of the Benefit Information table. For a single Copayment and/or Coinsurance, you may receive a Prescription Drug Product up to the stated supply limit. Note: Some products are subject to additional supply limits based on criteria that we have developed, subject to our periodic review and modification. The limit may restrict the amount dispensed per Prescription Order or Refill and/or the amount dispensed per month s supply, or may require that a minimum amount be dispensed. You may determine whether a Prescription Drug Product has been assigned a supply limit for dispensing through the Internet at [www.myuhc.com] or by calling Customer Care at the telephone number on your ID card. WPD.EPO.I.11.TX R1
Prior Authorization Requirements Before certain Prescription Drug Products are dispensed to you, either your Physician, your pharmacist or you are required to obtain prior authorization from us or our designee. The reason for obtaining prior authorization from us is to determine whether the Prescription Drug Product, in accordance with our approved guidelines, is each of the following: It meets the definition of a Covered Health Service. It is not an Experimental or Investigational or Unproven Service. We may also require you to obtain prior authorization from us or our designee so we can determine whether the Prescription Drug Product, in accordance with our approved guidelines, was prescribed by a Specialist Physician. Network Pharmacy Prior Authorization When Prescription Drug Products are dispensed at a Network Pharmacy, the prescribing provider, the pharmacist, or you are responsible for obtaining prior authorization from us. If you do not obtain prior authorization from us before the Prescription Drug Product is dispensed, you may pay more for that Prescription Order or Refill. The Prescription Drug Products requiring prior authorization are subject to our periodic review and modification. You may determine whether a particular Prescription Drug Product requires prior authorization through the Internet at [www.myuhc.com] or by calling Customer Care at the telephone number on your ID card. If you do not obtain prior authorization from us before the Prescription Drug Product is dispensed, you can ask us to consider reimbursement after you receive the Prescription Drug Product. You will be required to pay for the Prescription Drug Product at the pharmacy. You may seek reimbursement from us as described in the Certificate of Coverage (Certificate) in Section 5: How to File a Claim. [Therapeutic class charge and therapeutically equivalent charge (here and throughout) is variable by plan design.] When you submit a claim on this basis, you may pay more because you did not obtain prior authorization from us before the Prescription Drug Product was dispensed. The amount you are reimbursed will be based on the Prescription Drug Charge, less the required Copayment and/or Coinsurance [,Ancillary Charge] [,Therapeutic Class Charge] [,Therapeutically Equivalent Charge] and any deductible that applies. Benefits may not be available for the Prescription Drug Product after we review the documentation provided and we determine that the Prescription Drug Product is not a Covered Health Service or it is an Experimental or Investigational or Unproven Service. We may also require prior authorization for certain programs which may have specific requirements for participation and/ or activation of an enhanced level of Benefits associated with such programs. You may access information on available programs and any applicable prior authorization, participation or activation requirements associated with such programs through the Internet at [www.myuhc.com] or by calling Customer Care at the telephone number on your ID card. [Step Therapy] [Certain Prescription Drug Products for which Benefits are described under this Prescription Drug Rider or Pharmaceutical Products for which Benefits are described in your Certificate are subject to step therapy requirements. This means that in order to receive Benefits for such Prescription Drug Products and/or Pharmaceutical Products you are required to use a different Prescription Drug Product(s) or Pharmaceutical Product(s) first. You may determine whether a particular Prescription Drug Product or Pharmaceutical Product is subject to step therapy requirements through the Internet at [www.myuhc.com] or by calling Customer Care at the telephone number on your ID card.] What You Must Pay [The following bracketed provisions are variable based upon plan design.] [You are responsible for paying the [Annual Drug Deductible] [and] [Specialty Prescription Drug Product Annual Deductible].] [Benefits for Prescription Drug Products on the List of Preventive Medications are not subject to payment of the Annual Drug Deductible.] [Benefits for Preventive Care Medications are not subject to payment of the Annual Drug Deductible.] WPD.EPO.I.11.TX R1
[Benefits for [insulin] [or] [diabetic supplies] are not subject to payment of the Annual Drug Deductible.] [You are responsible for paying the Annual Deductible stated in the Schedule of Benefits which is attached to your Certificate before Benefits for Prescription Drug Products under this Rider are available to you.] [Benefits for Prescription Drug Products on the List of Preventive Medications are not subject to payment of the Annual Deductible.] [Benefits for Preventive Care Medications are not subject to payment of the Annual Deductible.] [Benefits for [insulin] [or] [diabetic supplies] are not subject to payment of the Annual Deductible.] You are responsible for paying the applicable Copayment and/or Coinsurance described in the Benefit Information table [, in addition to any Ancillary Charge] [[, in addition to any] [or] Therapeutic Class Charge] [[, in addition to any] [or] Therapeutically Equivalent Charge]. [You are not responsible for paying a Copayment and/or Coinsurance for Preventive Care Medications.] [ 1 Applies when the plan design includes the mandatory generic program.] [An Ancillary Charge may apply when a covered Prescription Drug Product is dispensed at your [1or the 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 tiered drug] [higher tier drug]. [An Ancillary Charge does not apply to any [Annual Drug Deductible] [,] [Annual Deductible] [,] [Specialty Prescription Drug Product Annual Deductible] [,] [or] [Out-of-Pocket Drug Maximum] [,] [or] [Out-of-Pocket Maximum] [or] [Specialty Prescription Drug Product Out-of- Pocket Maximum].]] [A Therapeutic Class Charge may apply when the Prescription Drug Charge of the Prescription Drug Product exceeds the Maximum Allowable Amount. You are responsible for the Therapeutic Class Charge and any applicable Copayment and/ or Coinsurance.] [A Therapeutically Equivalent Charge may apply when the Prescription Drug Charge of the Prescription Drug Product exceeds the Maximum Allowable Amount. You are responsible for the Therapeutically Equivalent Charge and any applicable Copayment and/or Coinsurance.] The amount you pay for any of the following under this Rider will not be included in calculating any Out-of-Pocket Maximum stated in your Certificate: [Copayments for Prescription Drug Products [,including Specialty Prescription Drug Products].] [Coinsurance for Prescription Drug Products [,including Specialty Prescription Drug Products].] [Ancillary Charges.] [Therapeutic Class Charges.] [Therapeutically Equivalent Charges.] [The Annual Drug Deductible.] [The Specialty Prescription Drug Product Annual Deductible.] [Any amount you pay for Prescription Drug Products for Infertility that exceeds the Infertility Annual Maximum Benefit.] [Any amount you pay for Prescription Drug Products for Infertility that exceeds the Infertility Maximum Policy Benefit.] Any non-covered drug product. You are responsible for paying 100% of the cost (the amount the pharmacy charges you) for any non-covered drug product and our contracted rates (our Prescription Drug Charge) will not be available to you. Payment Information [The following provisions are plan design variable.] [The Annual Drug Deductibles are calculated on a [calendar] [Policy] year basis.] WPD.EPO.I.11.TX R1
[The Specialty Prescription Drug Product Annual Deductibles are calculated on a [calendar] [Policy] year basis.] [The Out-of-Pocket Drug Maximums are calculated on a [calendar] [Policy] year basis.] [The Specialty Prescription Drug Product Out-of-Pocket Maximums are calculated on a [calendar] [Policy] year basis.] [The Infertility Annual Maximum Benefit is calculated on a [calendar] [Policy] year basis.] Emergency Care means health care services provided in a hospital emergency facility or other comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to, severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that the person s condition, sickness or injury is of such a nature that failure to get immediate medical care could result in: placing the patient s health in serious jeopardy; serious impairment to bodily functions; serious dysfunction of any bodily organ or part; serious disfigurement; or in the case of a pregnant woman, serious jeopardy to the health of the fetus. Prior authorization is not required for emergency services. Benefits are provided for Emergency Health Services provided by a non-network physician or provider. Urgent care is health services that are required to prevent serious deterioration of your health and/or as a result of an unforeseen sickness, injury or the onset of acute or severe symptoms. Urgent care health services and after hours care must be provided by a Network physician or provider for the services to be covered. Out-of-area services received from a non-network physician or provider are not covered except in cases of an emergency. The Insured Person is responsible for payment of all noncovered services and/or services provided by a non-network provider (except in the case of emergency or if specific Covered Health Services are not available from a Network provider, upon request from your Network provider, you may be eligible for Benefits when Covered Health Services are received from non-network providers) including the deductible, coinsurance, copayment and out-of-pocket expense amounts shown in the Schedule of Benefits. Benefits apply to Covered Health Services that are provided by a Network Physician or other Network provider. Benefits for facility services apply when Covered Health Services are provided at a Network facility. Benefits include Physician services provided in a Network facility by a Network or a non-network radiologist, anesthesiologist, pathologist, Emergency room Physician and consulting Physician. Benefits also include Covered Health Services received at an Urgent Care Center outside your geographic area and Emergency Health Services. When Covered Health Services [1(other than Emergency Health Services)] are provided at a Network facility by a non- Network [1Emergency care Physician] [,] [or] [radiologist] [,] [or] [anesthesiologist] [,] [or] [pathologist] [,] [or] [consulting Physician] [,] [or] [neonatologist] [,] [or] [intensivist] [,] [or] [assistant surgeon] [or] [surgical assistant], or at a Network clinic or Physician office by a non-network [Emergency care Physician] [,] [or] [radiologist] [,] [or] [anesthesiologist] [,] [or] [pathologist], Benefits will be reimbursed as set forth under Eligible Expenses as described at the end of the Schedule of Benefits. We do not Pay Benefits for Exclusions We will not pay Benefits for any of the services, treatments, items or supplies described in this section, even if either of the following is true: It is recommended or prescribed by a Physician. It is the only available treatment for your condition. The services, treatments, items or supplies listed in this section are not Covered Health Services, except as may be specifically provided for in Section 1: Covered Health Services or through a Rider to the Policy. Benefit Limitations When Benefits are limited within any of the Covered Health Service categories described in Section 1: Covered Health Services, those limits are stated in the corresponding Covered Health Service category in the Schedule of Benefits. Limits may also apply to some Covered Health Services that fall under more than one Covered Health Service category. When this occurs, those limits are also stated in the Schedule of Benefits under the heading Benefit Limits. Please review all limits carefully, as we will not pay Benefits for any of the services, treatments, items or supplies that exceed these Benefit WPD.EPO.I.11.TX R1
limits. Please note that in listing services or examples, when we say this includes, it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list is limited to. Prior Authorization We require prior authorization for certain Covered Health Services. In general, Network providers are responsible for obtaining prior authorization before they provide these services to you. There are some Benefits, however, for which you are responsible for obtaining prior authorization. Services for which prior authorization is required are identified below and in the Schedule of Benefits table within each Covered Health Service category. We recommend that you confirm with us that all Covered Health Services listed below have been prior authorized as required. Before receiving these services from a Network provider, you may want to contact us to verify that the Hospital, Physician and other providers are Network providers and that they have obtained the required prior authorization. Network facilities and Network providers cannot bill you for services they fail to prior authorize as required. You can contact us by calling the telephone number for Customer Care on your ID card. To obtain prior authorization, call the telephone number for Customer Care on your ID card. This call starts the utilization review process. Once you have obtained the authorization, please review it carefully so that you understand what services have been authorized and what providers are authorized to deliver the services that are subject to the authorization. The utilization review process is a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or settings. Such techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, retrospective review or similar programs. Covered Health Services which Require Prior Authorization Please note that prior authorization timelines apply. Refer to the applicable Benefit description in the Schedule of Benefits table to determine how far in advance you must obtain prior authorization. [Include bracketed variable benefit category listed below if: a) the benefit is included in the plan design and b) prior authorization is required. Include dollar amounts as applicable.] Ambulance - non-emergent air and ground. Clinical trials. [Congenital heart disease surgery.] [Dental services - accidental.] [Infertility services.] [In-vitro fertilization services.] [Obesity surgery.] [Speech and Hearing services.] Transplants. If you request a coverage determination at the time prior authorization is provided, the determination will be made based on the services you report you will be receiving. If the reported services differ from those actually received, our final coverage determination will be modified to account for those differences, and we will only pay Benefits based on the services actually delivered to you. If you choose to receive a service that has been determined not to be a Medically Necessary Covered Health Service, you will be responsible for paying all charges and no Benefits will be paid. Care Management When you seek prior authorization as required, we will work with you to implement the care management process and to provide you with information about additional services that are available to you, such as disease management programs, WPD.EPO.I.11.TX R1
health education, and patient advocacy. If you are undergoing a course of treatment from a Network provider at the time that Network provider is no longer contracted with us, you may be entitled to continue that care covered at the Network benefit level. Continuity of care is available in special circumstances in which the treating Physician or health care provider reasonably believes discontinuing care by the treating Physician could cause harm to the Covered Person. Special circumstances include Covered Persons with a disability acute condition, life-threatening illness or past the 24th week of Pregnancy. The continuity of care request must be submitted by the treating Physician or provider. If continuity of care is approved, it may not be continued beyond 90 days after the Physician or provider is no longer contracted with us, if the Covered Person has been diagnosed as having a terminal illness at the time of the termination, or the expiration of the nine month period after the effective date of the termination. If the Covered Person is past the 24th week of Pregnancy at the time of termination, coverage at the Network level will continue through the delivery of the child, immediate postpartum care and the follow-up checkup within the six week period after delivery. If you have questions regarding this transition of care reimbursement policy or would like help determining whether you are eligible for transition of care Benefits, please contact Customer Care at the telephone number on your ID card. To resolve a question, complaint, or appeal, contact Customer Care at the telephone number shown on your ID card. Customer Care representatives are available to take your call during regular business hours, Monday through Friday. If you would rather send your complaint to us in writing, the Customer Care representative can provide you with the appropriate address. We will promptly investigate each complaint. The total time for acknowledgement, investigation and resolution of the complaint shall not exceed 30 calendar days after we receive the written complaint. Complaints concerning presently occurring Emergencies or denials of continued stays for hospitalization shall be investigated and resolved in accordance with the medical immediacy, and will not exceed one business day from receipt of the complaint. We will not engage in any retaliatory action against any Covered Person, anyone who has filed a complaint on behalf of the Covered Person or against a physician or provider. For a list of Network providers go to [www.myuhc.com] or call Customer Care at the telephone number on your ID card. Network providers may be found throughout the entire state of Texas, through the UnitedHealthcare Choice network. A list of network providers can be obtained by contacting us at the address or telephone number at the beginning of this summary or you may visit the UnitedHealthcare provider lookup website at [www.providerlookuponline.com/uhc/po7/ Search.aspx]. If you would like a printed copy of providers, we will send it free of charge upon request. The number of insureds in the service area or region, the number of preferred providers in the areas of practice, including internal medicine, family/general practice, pediatric practitioner practice, obstetrics and gynecology, anesthesiology, psychiatry, and general surgery, and the number of preferred provider hospitals in the service area may be found at [UHICEPO Access Plan and Waiver]. If you would like a printed copy of this information, we will send it free of charge upon request. Network adequacy including any waivers can also be obtained by contacting us at the telephone number listed above, or you may go to [UHICEPO Access Plan and Waiver]. A printed copy may be requested and provided free of charge. WPD.EPO.I.11.TX R1
The number of contracted providers by specialty and hospitals are listed below by region. Region 1 Panhandle including Amarillo and Lubbock Region 2 Northwest Texas including Wichita Falls and Abilene Region 3 Metroplex including Fort Worth and Dallas Region 4 Northeast Texas including Tyler Region 5 Southeast Texas including Beaumont Region 6 Gulf Coast including Houston and Huntsville Region 7 Central Texas including Austin and Waco Region 8 South Central Texas including San Antonio Region 9 West Texas, including Midland, Odessa and San Angelo Region 10 Far West Texas including El Paso Region 11 Rio Grande Valley including Brownsville, Corpus Christi, and Laredo REGION 1 2 3 4 5 6 7 8 9 10 11 Allergy 10 4 158 19 11 391 129 65 10 9 18 Anesthesia 27 23 120 29 14 69 64 48 12 7 32 Cardiology 123 49 1,189 306 193 1,443 611 591 93 72 263 Dermatology 26 11 424 71 11 384 211 114 17 12 20 Endocrinology 35 3 280 24 10 321 90 75 13 15 22 Gastroenterology 44 28 478 114 31 679 224 207 26 34 76 Hematology / Oncology 77 29 928 83 55 1,138 331 387 63 60 134 Infectious Disease Medicine 14 4 180 24 8 265 43 54 11 13 35 Neonatology 29 4 615 20 14 593 239 190 14 46 103 Nephrology 45 6 431 61 42 573 373 283 23 43 109 Neurology 33 32 532 65 31 693 186 169 19 20 59 OB/GYN 164 46 1,376 211 69 1,511 649 581 90 133 342 Ophthalmology 67 35 621 154 73 952 342 320 50 51 219 Orthopedic Surgery 102 31 924 168 55 849 425 401 75 140 125 Otorhino-laryngology 31 17 338 54 21 487 184 138 19 29 69 Pathology 28 24 96 27 16 63 72 54 21 11 39 PCPs - Adult 819 476 3,993 1,085 476 4,428 2,946 1,896 458 432 1,125 PCPs - Pediatric 745 394 3,560 852 380 4,185 2,736 1,731 347 413 1,296 PCPs - Pediatrician 189 51 1,298 165 86 2,021 711 499 91 198 600 Pediatric Specialists 95 36 1,095 12 10 1,876 417 351 51 61 152 Podiatry 31 18 426 88 32 491 180 189 34 49 95 Pulmonary Medicine 48 18 331 93 24 516 147 123 15 32 131 Radiology 42 40 114 30 18 73 75 54 30 11 43 Rheumatology 12 7 127 20 11 165 61 89 9 7 14 Surgery 130 42 821 148 96 858 352 358 55 64 185 Surgery Specialized 113 27 1,107 145 61 1,080 439 475 56 70 131 Urology 49 11 338 100 25 447 143 109 23 32 50 Ambulatory Surgery 62 53 253 53 35 185 123 98 34 23 68 Dialysis Center 17 7 102 22 10 113 45 61 8 17 37 Disability/ Medical Rehab 5 3 60 13 12 40 12 31 5 4 118 Extended/ Skilled Care Facility 23 20 186 39 27 95 48 50 7 8 41 General/Acute Care Hospitals 50 42 138 35 26 116 83 61 30 13 55 Home Health 106 40 272 88 76 299 112 108 34 44 200 Hospice 17 9 45 6 5 31 26 24 6 5 7 Laboratory 12 6 99 22 7 73 42 48 4 7 20 MRI 56 43 185 39 30 168 93 83 30 14 69 Radiation Oncology Facilities 1 15 3 1 7 3 XRay & Radiology 55 43 235 43 33 194 139 145 31 22 111 WPD.EPO.I.11.TX R1
Region 1 Panhandle including Amarillo and Lubbock Region 2 Northwest Texas including Wichita Falls and Abilene Region 3 Metroplex including Fort Worth and Dallas Region 4 Northeast Texas including Tyler Region 5 Southeast Texas including Beaumont Region 6 Gulf Coast including Houston and Huntsville Active access plans are in the place in the following specialties/region: Region 7 Central Texas including Austin and Waco Region 8 South Central Texas including San Antonio Region 9 West Texas, including Midland, Odessa and San Angelo Region 10 Far West Texas including El Paso Region 11 Rio Grande Valley including Brownsville, Corpus Christi, and Laredo REGION 1 2 3 4 5 6 7 8 9 10 11 Primary Care Physicians yes Pediatric Physicians yes yes yes yes yes Obstetrics and yes yes yes yes yes yes yes yes Gynecology Anesthesiology yes yes yes yes yes The plan s membership by region is below: 1 2 3 4 5 6 7 8 9 10 11 699 255 25,646 2,910 931 22,914 5,192 8,161 566 243 4,552 Texas Department of Insurance Notice An exclusive provider benefit plan provides no benefits for services you receive from out-of-network providers, with specific exceptions as described in your policy and below. You have the right to an adequate network of preferred providers (known as network providers ). If you believe that the network is inadequate, you may file a complaint with the Texas Department of Insurance. If your insurer approves a referral for out-of-network services because no preferred provider is available, or if you have received out-of-network emergency care, your insurer must, in most cases, resolve the nonpreferred provider s bill so that you only have to pay any applicable coinsurance, copay, and deductible amounts. You may obtain a current directory of preferred providers at the following website: myuhc.com or by calling the telephone number on your ID card for assistance in finding available preferred providers. If you relied on materially inaccurate directory information, you may be entitled to have an out-of-network claim paid at the in-network level of benefits. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. Health Plan coverage provided by or through UnitedHealthcare of Texas, Inc. MT-994995.0 12/15 2015 United HealthCare Services, Inc. M53789 Texas EPO Plans - 2011 COC Series WPD.EPO.I.11.TX R1