Connecticut - UnitedHealthcare

Transcription

UnitedHealthcare Insurance Company
Choice Plus Individual Medical Policy
185 Asylum Street
Hartford, Connecticut 06103-3408
Sa
m
pl
e
1-800-357-1371
Agreement and Consideration
We will pay Benefits as set forth in this Policy. This Policy is issued in exchange for and on the basis of
the statements made on your application and payment of the first Premium. It takes effect on the effective
date shown above. Coverage will remain in force until the first Premium due date, and for such further
periods for which Premium payment is received by us when due, subject to the renewal provision below.
Coverage will begin at 12:01 a.m. and end at 12:00 midnight in the time zone where you live.
Guaranteed Renewable Subject to Listed Conditions
You may keep coverage in force by timely payment of the required Premiums under this Policy or under
any subsequent coverage you have with us. This Policy will renew on January 1 of each calendar year.
However, we may refuse renewal if we refuse to renew all policies issued on this form, with the same type
and level of Benefits, to residents of the state where you then live, or there is fraud or a material
misrepresentation made by or with the knowledge of a Covered Person in filing a claim for Benefits.
On January 1 of each calendar year, we may change the rate table used for this Policy form. Each
Premium will be based on the rate table in effect on that Premium's due date. Some of the factors used in
determining your Premium rates are the Policy plan, tobacco use status of Covered Persons, type and
level of Benefits and place of residence on the Premium due date and age of Covered Persons as of the
effective date or renewal date of coverage. Premium rates are expected to increase over time.
At least 31 days' notice of any plan to take an action or make a change permitted by this clause will be
mailed to you at your last address as shown in our records.
IEXPOL.I.15.CT
1
10-Day Right to Examine and Return this Policy
Please read this Policy. If you are not satisfied, you may notify us within 10 days after you received it. Any
Premium paid will be refunded, less claims paid. This Policy will then be void from its start.
This Policy is signed for us as of the effective date as shown above.
IEXPOL.I.15.CT
2
This Policy
This Policy is a legal document between UnitedHealthcare Insurance Company and you to provide
Benefits to Covered Persons, subject to the terms, conditions, exclusions and limitations of this Policy.
We issue this Policy based on the Policyholder's application and payment of the required Premium.
This Policy includes:

The Schedule of Benefits.

The Policyholder's application.

Amendments.
Changes to the Document
We may from time to time modify this Policy by attaching legal documents called Riders and/or
Amendments that may change certain provisions of this Policy. When that happens we will send you a
new Policy, Rider or Amendment pages.
No one can make any changes to this Policy unless those changes are in writing.
Other Information You Should Have
We have the right to change, interpret, modify, withdraw or add Benefits, or to terminate this Policy, as
permitted by law.
This Policy will remain in effect as long as the Premium is paid when due, subject to the renewal and
termination provisions of this Policy.
We are delivering this Policy in the State of Connecticut. This Policy is governed by the laws of the State
of Connecticut.
IEXPOL.I.15.CT
3
Introduction to Your Policy
We are pleased to provide you with this Policy. This Policy describes your Benefits, as well as your rights
and responsibilities, under this Policy.
How to Use this Document
We encourage you to read your Policy and any attached Riders and/or Amendments carefully.
We especially encourage you to review the Benefit limitations of this Policy by reading the attached
Schedule of Benefits along with Section 1: Covered Health Services and Section 2: Exclusions and
Limitations. You should also carefully read Section 7: General Legal Provisions to better understand how
this Policy and your Benefits work. You should call us if you have questions about the limits of the
coverage available to you.
Many of the sections of this Policy are related to other sections of the document. You may not have all of
the information you need by reading just one section. We also encourage you to keep your Policy and
Schedule of Benefits and any attachments in a safe place for your future reference.
If there is a conflict between this Policy and any summaries provided to you, this Policy will control.
Please be aware that your Physician is not responsible for knowing or communicating your Benefits.
Information about Defined Terms
Because this Policy is a legal document, we want to give you information about the document that will
help you understand it. Certain capitalized words have special meanings. We have defined these words
in Section 8: Defined Terms. You can refer to Section 8: Defined Terms as you read this document to
have a clearer understanding of your Policy.
When we use the words "we," "us," and "our" in this document, we are referring to UnitedHealthcare
Insurance Company. When we use the words "you" and "your," we are referring to people who are
Covered Persons, as that term is defined in Section 8: Defined Terms.
Don't Hesitate to Contact Us
Throughout the document you will find statements that encourage you to contact us for further
information. Whenever you have a question or concern regarding your Benefits, please call us using the
telephone number for Customer Care listed on your identification (ID) card. It will be our pleasure to assist
you.
IEXPOL.I.15.CT
4
Your Responsibilities
Be Enrolled and Pay Required Premiums
Benefits are available to you only if you are enrolled for coverage under this Policy. Your enrollment
options, and the corresponding dates that coverage begins, are listed in Section 3: When Coverage
Begins and Premiums. To be enrolled with us and receive Benefits, all of the following apply:

Your enrollment must be in accordance with this Policy, including the eligibility requirements.

You must qualify as a Policyholder or his or her Dependent as those terms are defined in Section
8: Defined Terms.

You must pay Premium as required.
Be Aware this Policy Does Not Pay for All Health Services
Your right to Benefits is limited to Covered Health Services, subject to the conditions, limitations and
exclusions of this Policy. The extent of this Policy's payments for Covered Health Services and any
obligation that you may have to pay for a portion of the cost of those Covered Health Services is set forth
in the Schedule of Benefits.
Decide What Services You Should Receive
Care decisions are between you and your Physicians. We do not make decisions about the kind of care
you should or should not receive.
Choose Your Physician
It is your responsibility to select the health care professionals who will deliver care to you. We arrange for
Physicians and other health care professionals and facilities to participate in a Network. Our credentialing
process confirms public information about the professionals' and facilities' licenses and other credentials,
but does not assure the quality of their services. These professionals and facilities are independent
practitioners and entities that are solely responsible for the care they deliver.
Obtain Prior Authorization
Some Covered Health Services require prior authorization. In general, Physicians and other health care
professionals who participate in a Network are responsible for obtaining prior authorization. However, if
you choose to receive Covered Health Services from a non-Network provider, you are responsible for
obtaining prior authorization before you receive the services. For detailed information on the Covered
Health Services that require prior authorization, please refer to the Schedule of Benefits.
Pay Your Share
You must meet any applicable deductible and pay a Copayment and/or Coinsurance for most Covered
Health Services. These payments are due at the time of service or when billed by the Physician, provider
or facility. Copayment and Coinsurance amounts are listed in the Schedule of Benefits. You must also
pay any amount that exceeds Eligible Expenses.
Pay the Cost of Excluded Services
You must pay the cost of all excluded services and items. Review Section 2: Exclusions and Limitations
to become familiar with this Policy's exclusions.
IEXPOL.I.15.CT
5
Show Your ID Card
You should show your identification (ID) card every time you request health services. If you do not show
your ID card, the provider may fail to bill the correct entity for the services delivered, and any resulting
delay may mean that you will be unable to collect any Benefits otherwise owed to you.
File Claims with Complete and Accurate Information
When you receive Covered Health Services from a non-Network provider, you are responsible for
requesting payment from us. You must file the claim in a format that contains all of the information we
require, as described in Section 5: How to File a Claim.
Use Your Prior Health Care Coverage
If you have prior coverage that, as required by state law, extends benefits for a particular condition or a
disability, we will not pay Benefits for health services for that condition or disability until the prior coverage
ends. We will pay Benefits as of the day your coverage begins under this Policy for all other Covered
Health Services that are not related to the condition or disability for which you have other coverage.
IEXPOL.I.15.CT
6
Our Responsibilities
Determine Benefits
We do not make decisions about the kind of care you should or should not receive. You and your
providers must make those treatment decisions.
We will determine the following:

Interpret Benefits and the other terms, limitations and exclusions set out in this Policy, the
Schedule of Benefits and any Riders and/or Amendments.

Make factual determinations relating to Benefits.
We may delegate this authority to other persons or entities that may provide administrative services for
this Policy, such as claims processing. The identity of the service providers and the nature of their
services may be changed from time to time, as we determine. In order to receive Benefits, you must
cooperate with those service providers.
Pay for Our Portion of the Cost of Covered Health Services
We pay Benefits for Covered Health Services as described in Section 1: Covered Health Services and in
the Schedule of Benefits, unless the service is excluded in Section 2: Exclusions and Limitations. This
means we only pay our portion of the cost of Covered Health Services. It also means that not all of the
health care services you receive may be paid for (in full or in part) by this Policy.
Pay Network Providers
It is the responsibility of Network Physicians and facilities to file for payment from us. When you receive
Covered Health Services from Network providers, you do not have to submit a claim to us.
Pay for Covered Health Services Provided by Non-Network Providers
In accordance with any state prompt pay requirements, we will pay Benefits after we receive your request
for payment that includes all required information. See Section 5: How to File a Claim.
Review and Determine Benefits in Accordance with our
Reimbursement Policies
We develop our reimbursement policy guidelines in accordance with one or more of the following
methodologies:

As indicated in the most recent edition of the Current Procedural Terminology (CPT), a publication
of the American Medical Association, and/or the Centers for Medicare and Medicaid Services
(CMS).

As reported by generally recognized professionals or publications.

As used for Medicare.

As determined by medical staff and outside medical consultants pursuant to other appropriate
sources or determinations that we accept.
Following evaluation and validation of certain provider billings (e.g., error, abuse and fraud reviews), our
reimbursement policies are applied to provider billings. We share our reimbursement policies with
Physicians and other providers in our Network through our provider website. Network Physicians and
providers may not bill you for the difference between their contract rate (as may be modified by our
reimbursement policies) and the billed charge. However, non-Network providers are not subject to this
prohibition, and may bill you for any amounts we do not pay, including amounts that are denied because
one of our reimbursement policies does not reimburse (in whole or in part) for the service billed. You may
IEXPOL.I.15.CT
7
obtain copies of our reimbursement policies for yourself or to share with your non-Network Physician or
provider by calling Customer Care at the telephone number on your ID card.
Offer Health Education Services to You
From time to time, we may provide you with access to information about additional services that are
available to you, such as disease management programs, health education and patient advocacy. It is
solely your decision whether to participate in the programs, but we recommend that you discuss them
with your Physician.
IEXPOL.I.15.CT
8
Table of Contents
Section 1: Covered Health Services ........................................................................................................... 10 Section 2: Exclusions and Limitations......................................................................................................... 30 Section 3: When Coverage Begins and Premiums ..................................................................................... 41 Section 4: When Coverage Ends ................................................................................................................ 44 Section 5: How to File a Claim .................................................................................................................... 47 Section 6: Questions, Complaints and Appeals .......................................................................................... 49 Section 7: General Legal Provisions ........................................................................................................... 58 Section 8: Defined Terms............................................................................................................................ 64 Section 9: Outpatient Prescription Drug Coverage ..................................................................................... 74
Section 10: Pediatric Dental Services ........................................................................................................ 82
Section 11: Pediatric Vision Care Services................................................................................................. 88 IEXPOL.I.15.CT
9
Section 1: Covered Health Services
Benefits for Covered Health Services
Benefits are available only if all of the following are true:

The health care service, supply or Pharmaceutical Product is only a Covered Health Service if it is
Medically Necessary. (See definitions of Medically Necessary and Covered Health Service in
Section 8: Defined Terms.) The fact that a Physician or other provider has performed or prescribed
a procedure or treatment, or the fact that it may be the only available treatment for a Sickness,
Injury, Mental Illness, substance-related and addictive disorders, disease or its symptoms does not
mean that the procedure or treatment is a Covered Health Service under this Policy.

Covered Health Services are received while this Policy is in effect.

Covered Health Services are received prior to the date that any of the individual termination
conditions listed in Section 4: When Coverage Ends occurs.

The person who receives Covered Health Services is a Covered Person and meets all eligibility
requirements.
This section describes Covered Health Services for which Benefits are available. Please refer to the
attached Schedule of Benefits for details about:

The amount you must pay for these Covered Health Services (including any Annual Deductible,
Copayment and/or Coinsurance).

Any limit that applies to these Covered Health Services (including visit, day and dollar limits on
services).

Any limit that applies to the amount of Eligible Expenses you are required to pay in a year (Out-ofPocket Maximum).

Any responsibility you have for obtaining prior authorization or notifying us.
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."
1. Abortion Services
Benefits include services for a therapeutic abortion, that is an abortion recommended by a Provider
performed to save the life or health of the mother, or as a result of incest or rape.
2. Ambulance Services
We will pay Benefits as stated in the Schedule of Benefits for Medically Necessary ground or air
ambulance.
3. Clinical Trials
Routine patient care costs incurred during participation in a qualifying clinical trial for the treatment of:

Cancer or other life-threatening disease or condition. For purposes of this benefit, a life-threatening
disease or condition is one from which the likelihood of death is probable unless the course of the
disease or condition is interrupted.

Cardiovascular disease (cardiac/stroke) which is not life threatening, for which, as we determine, a
clinical trial meets the qualifying clinical trial criteria stated below.
IEXPOL.I.15.CT
10

Surgical musculoskeletal disorders of the spine, hip and knees, which are not life threatening, for
which, as we determine, a clinical trial meets the qualifying clinical trial criteria stated below.

Disabling or life-threatening chronic disease.

Other diseases or disorders which are not life threatening for which, as we determine, a clinical trial
meets the qualifying clinical trial criteria stated below.
Benefits include the reasonable and necessary items and services used to prevent, diagnose and treat
complications arising from participation in a qualifying clinical trial.
Benefits are available only when the Covered Person is clinically eligible for participation in the qualifying
clinical trial as defined by the researcher.
Routine patient care costs for qualifying clinical trials include:

Covered Health Services for which Benefits are typically provided absent a clinical trial.

Covered Health Services required solely for the provision of the Experimental or Investigational
Service(s) or item, the clinically appropriate monitoring of the effects of the item or service, or the
prevention of complications.

Covered Health Services needed for reasonable and necessary care arising from the provision of
an Experimental or Investigational Service(s) or item.
Routine costs for clinical trials do not include:

The Experimental or Investigational Service(s) or item. The only exceptions to this are:

Certain Category B devices.

Certain promising interventions for patients with terminal illnesses.

Other items and services that meet specified criteria in accordance with our medical and
drug policies.

Items and services provided solely to satisfy data collection and analysis needs and that are not
used in the direct clinical management of the patient.

A service that is clearly inconsistent with widely accepted and established standards of care for a
particular diagnosis.

Items and services provided by the research sponsors free of charge for any person enrolled in the
trial.
Routine patient care costs are subject to the terms, conditions, restrictions, exclusions and limitations of
this Policy. If treatment is not available at an in-network facility, coverage may be provided at an out-ofnetwork hospital at no greater cost than if such treatment was available in-network.
With respect to cancer or other disabling or life-threatening diseases or conditions, a qualifying clinical
trial is 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 disabling or life-threatening diseases or conditions and
which meets any of the following criteria in the bulleted list below.
With respect to cardiovascular disease or musculoskeletal disorders of the spine, hip and knees and
other diseases or disorders which are not disabling or life-threatening diseases or conditions, a qualifying
clinical trial is a Phase I, Phase II, or Phase III clinical trial that is conducted in relation to the detection or
treatment of such disabling or life-threatening diseases or conditions and which meets any of the
following criteria in the bulleted list below.

Federally funded trials. The study or investigation is approved or funded (which may include
funding through in-kind contributions) by one or more of the following:

National Institutes of Health (NIH). (Includes National Cancer Institute (NCI).)

Centers for Disease Control and Prevention (CDC).
IEXPOL.I.15.CT
11

Agency for Healthcare Research and Quality (AHRQ).

Centers for Medicare and Medicaid Services (CMS).

A cooperative group or center of any of the entities described above or the Department of
Defense (DOD) or the Veterans Administration (VA).

A qualified non-governmental research entity identified in the guidelines issued by the
National Institutes of Health for center support grants.

The Department of Veterans Affairs, the Department of Defense or the Department of
Energy as long as the study or investigation has been reviewed and approved through a
system of peer review that is determined by the Secretary of Health and Human Services to
meet both of the following criteria:
♦
Comparable to the system of peer review of studies and investigations used by the
National Institutes of Health.
♦
Ensures unbiased review of the highest scientific standards by qualified individuals
who have no interest in the outcome of the review.

The study or investigation is conducted under an investigational new drug application reviewed by
the U.S. Food and Drug Administration.

The study or investigation is a drug trial that is exempt from having such an investigational new
drug application.

The clinical trial must have a written protocol that describes a scientifically sound study and have
been approved by all relevant institutional review boards (IRBs) before participants are enrolled in
the trial. We may, at any time, request documentation about the trial to confirm that the clinical trial
meets current standards for scientific merit and has the relevant IRB approvals.

The subject or purpose of the trial must be the evaluation of an item or service that meets the
definition of a Covered Health Service and is not otherwise excluded under this Policy.
4. Diabetes Services
Diabetes Self-Management and Training/Diabetic Eye Examinations/Foot Care
Outpatient self-management training for the treatment of insulin dependent diabetes, insulin-using
diabetes, gestational diabetes, and non-insulin using diabetes. Diabetes outpatient self-management
training, education and medical nutrition therapy services must be prescribed by a licensed health care
professional who has appropriate state licensing authority. Outpatient self-management training includes,
but is not limited to, education and medical nutrition therapy. The training must be given by a certified
registered or licensed health care professional trained in the care and management of diabetes.
Coverage includes:

Initial training visit, up to 10 hours, after you are diagnosed with diabetes, for the care and
management of diabetes, including but not limited to:

Counseling in nutrition.

The use of equipment and supplies

Training and education, up to four hours, as a result of a subsequent diagnosis by a
Physician of a significant change in your symptoms or condition which require modification of
your program of self-management of diabetes.

Training and education, up to four hours, because of the development of new techniques
and treatments.
IEXPOL.I.15.CT
12
Benefits under this section also include medical eye examinations (dilated retinal examinations) and
preventive foot care for Covered Persons with diabetes.
Diabetic Self-Management Items
Insulin pumps and supplies for the management and treatment of diabetes, based upon the medical
needs of the Covered Person. An insulin pump is subject to all the conditions of coverage stated under
Durable Medical Equipment. Benefits for diabetes equipment that meets the definition of Durable Medical
Equipment are not subject to the limit stated under Durable Medical Equipment. Benefits for blood
glucose monitors, insulin, insulin syringes with needles, blood glucose and urine test strips, ketone test
strips and tablets and lancets and lancet devices are described in Section 9: Outpatient Prescription Drug
Coverage..
5. Durable Medical Equipment
Durable Medical Equipment that meets each of the following criteria:

Ordered or provided by a Physician for outpatient use primarily in a home setting.

Used for medical purposes.

Not consumable or disposable except as needed for the effective use of covered Durable Medical
Equipment.

Not of use to a person in the absence of a disease or disability.
Benefits under this section include Durable Medical Equipment provided to you by a Physician.
If more than one piece of Durable Medical Equipment can meet your functional needs, Benefits are
available only for the equipment that meets the minimum specifications for your needs.
Examples of Durable Medical Equipment include:

Equipment to assist mobility, such as a standard wheelchair.

A standard Hospital-type bed.

Oxygen and the rental of equipment to administer oxygen (including tubing, connectors and
masks).

Delivery pumps for tube feedings (including tubing and connectors).

Negative pressure wound therapy pumps (wound vacuums).

Braces, including necessary adjustments to shoes to accommodate braces. Braces that stabilize
an injured body part and braces to treat curvature of the spine are considered Durable Medical
Equipment and are a Covered Health Service. Braces that straighten or change the shape of a
body part are orthotic devices, and are excluded from coverage. Dental braces are also excluded
from coverage.

Mechanical equipment necessary for the treatment of chronic or acute respiratory failure (except
that air-conditioners, humidifiers, dehumidifiers, air purifiers and filters and personal comfort items
are excluded from coverage).

Burn garments.

Insulin pumps and all related necessary supplies as described under Diabetes Services.

External cochlear devices and systems. Benefits for cochlear implantation are provided under the
applicable medical/surgical Benefit categories in this Policy.

Hearing aids for Enrolled dependents who are under the age of 12.
Benefits under this section do not include any device, appliance, pump, machine, stimulator, or monitor
that is fully implanted into the body.
IEXPOL.I.15.CT
13
We will decide if the equipment should be purchased or rented.
Benefits are available for repairs and replacement, except that:

Benefits for repair and replacement do not apply to damage due to misuse, malicious breakage or
gross neglect.

Benefits are not available to replace lost or stolen items.
6. Emergency Health Services - Outpatient
Services that are required to stabilize or initiate treatment in an Emergency. Emergency Health Services
must be received on an outpatient basis at a Hospital or Alternate Facility.
Coverage includes Emergency Health Services due to accidental ingestion or consumption of a controlled
drug. A "controlled drug" is a substance such as cocaine, morphine, hallucinogens, etc. It does not
include alcohol, nicotine or caffeine.
Benefits under this section include the facility charge, supplies and all professional services required to
stabilize your condition and/or initiate treatment. This includes placement in an observation bed for the
purpose of monitoring your condition (rather than being admitted to a Hospital for an Inpatient Stay).
Benefits under this section are not available for services to treat a condition that does not meet the
definition of an Emergency.
7. Home Health Care
Services received from a Home Health Agency that are both of the following:

Ordered by a Physician.

Provided in your home by a registered nurse, or provided by either a home health aide or licensed
practical nurse and supervised by a registered nurse.
Benefits are available only when the Home Health Agency services are provided on a part-time,
Intermittent Care schedule and when skilled care is required.
Benefits are available for:

Part-time intermittent home nursing care by or supervised by a registered professional nurse.

Part-time or intermittent home health aide services.
Home Health Agency services include physical, occupational or speech therapy.
Benefits are available for the following items to the extent that they would have been available if the
Covered Person were confined to a Hospital:

Medical supplies.

Drugs and medicine.

Laboratory services.
Medical social services, including but not limited to those provided to or for the benefit of a Covered
Person diagnosed by a Physician as terminally ill with a prognosis of six months or less to live. Medical
social services are services rendered under the direction of a Physician by a qualified social worker.
These services include, but are not limited to:

Assessment of the social, psychological and family problems related to or arising out of such
Covered Person's illness and treatment.
IEXPOL.I.15.CT
14

Appropriate action and utilization of community resources to assist in resolving such problems.

Participation in the development of the overall plan of treatment for such Covered Person.
Skilled care is skilled nursing, skilled teaching and skilled rehabilitation services when all of the following
are true:

It must be delivered or supervised by licensed technical or professional medical personnel in order
to obtain the specified medical outcome, and provide for the safety of the patient.

It is ordered by a Physician.

It is not delivered for the purpose of assisting with activities of daily living, including dressing,
feeding, bathing or transferring from a bed to a chair.

It requires clinical training in order to be delivered safely and effectively.

It is not Custodial Care.
We will determine if Benefits are available by reviewing both the skilled nature of the service and the need
for Physician-directed medical management. A service will not be determined to be "skilled" simply
because there is not an available caregiver.
8. Hospice Care
Hospice care that is recommended by a Physician. Hospice care is an integrated program that provides
comfort and support services for the terminally ill. Hospice care includes physical, psychological, social,
spiritual and respite care for the terminally ill person and short-term grief counseling for immediate family
members while the Covered Person is receiving hospice care. Benefits are available when hospice care
is received from a licensed hospice agency.
Please contact us for more information regarding our guidelines for hospice care. You can contact us at
the telephone number on your ID card.
9. Hospital - Inpatient Stay
Services and supplies provided during an Inpatient Stay in a Hospital. Benefits are available for:

Supplies and non-Physician services received during the Inpatient Stay.

Room and board in a Semi-private Room (a room with two or more beds).

Physician services for radiologists, anesthesiologists, pathologists and Emergency room
Physicians. (Benefits for other Physician services are described under Physician Fees for Surgical
and Medical Services.)
We will pay Benefits for an Inpatient Stay of at least 48 hours following a mastectomy or lymph node
dissection. We will pay Benefits for a longer Inpatient Stay if it is recommended by the Physician after
conferring with the patient.
10. Lab, X-Ray and Diagnostics - Outpatient
Services for Sickness and Injury-related diagnostic purposes, received on an outpatient basis at a
Hospital or Alternate Facility or in a Physician's office include:

Lab and radiology/X-ray.

Mammography

Comprehensive ultrasound screening of an entire breast or breasts if a mammogram demonstrates
heterogeneous or dense breast tissue based on the Breast Imaging Reporting and Data System
established by the American College of Radiology or if a woman is at increased risk for breast
cancer due to family history or prior personal history of breast cancer, positive genetic testing or
other indications as determined by a woman's physician or advanced practice registered nurse.
IEXPOL.I.15.CT
15

Magnetic resonance imaging of an entire breast or breasts in accordance with guidelines
established by the American Cancer Society.
Benefits under this section include:

The facility charge and the charge for supplies and equipment.

Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician
services are described under Physician Fees for Surgical and Medical Services.)

Prostate Specific Antigen (PSA) tests to screen for prostate cancer for men who are symptomatic
or whose biological father or brother has been diagnosed with prostate cancer, and for all men fifty
years of age or older. The treatment of prostate cancer is covered provided such treatment is
medically necessary and in accordance with guidelines established by the National Comprehensive
Cancer Network, the American Cancer Society or the American Society of Clinical Oncology.
Lab, X-ray and diagnostic services for preventive care are described under Preventive Care Services.
CT scans, PET scans, MRI, MRA, nuclear medicine and major diagnostic services are described under
Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient.
11. Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear
Medicine - Outpatient
Services for CT scans, PET scans, MRI, MRA, nuclear medicine and major diagnostic services received
on an outpatient basis at a Hospital or Alternate Facility or in a Physician's office.


Please refer to our provider directory located on our website at www.myuhc.com for assistance with
identifying the different types of facilities.
12. Mental Health Services
Mental Health Services include those received on an inpatient basis in a Hospital or an Alternate Facility,
and those received on an outpatient basis in a provider's office or at an Alternate Facility. Certain Mental
Health services require prior authorization. Please refer to your Schedule of Benefits under the heading
Covered Health Services which Require Prior Authorization for a detail list of services that require prior
authorization.
Benefits include the following services provided on either an inpatient or outpatient basis:

Diagnostic evaluations and assessment.

Treatment planning.

Treatment and/or procedures.

Referral services.

Medication management.

Individual, family, therapeutic group and provider-based case management services.

Crisis intervention.

Partial Hospitalization/Day Treatment.

Services at a Residential Treatment Facility. Confinement in a Residential Treatment Facility must
be based on an Individual Treatment Plan prescribed by the attending physician and approved by
IEXPOL.I.15.CT
16
the Mental Health/Substance Use Disorder Designee. For the purpose of this benefit, all of the
following criteria must be met:


The Covered Person has a serious mental illness which substantially impairs the person's
thought, perception of reality, emotional process, or judgment or grossly impairs behavior as
apparent by recent disturbed behavior; and

The Covered Person, upon an assessment by a Physician, psychiatrist, psychologist, or
clinical social worker, cannot be effectively treated in an acute care, Partial
Hospitalization/Day Treatment, Intensive Outpatient Treatment or outpatient setting.
Intensive Outpatient Treatment.
The Mental Health/Substance-Related and Addictive Disorders Designee determines coverage for all
levels of care. If an Inpatient Stay is required, it is covered on a Semi-private Room basis.
We encourage you to contact the Mental Health/Substance-Related and Addictive Disorders Designee for
referrals to providers and coordination of care.
Special Mental Health Programs and Services
Special programs and services that are contracted under the Mental Health/Substance-Related and
Addictive Disorders Designee may become available to you as a part of your Mental Health Services
Benefit. The Mental Health Services Benefits and financial requirements assigned to these programs or
services are based on the designation of the program or service to inpatient, Partial Hospitalization/Day
Treatment, Intensive Outpatient Treatment, outpatient or a Transitional Care category of Benefit use.
Special programs or services provide access to services that are beneficial for the treatment of your
Mental Illness which may not otherwise be covered under this Policy. You must be referred to such
programs through the Mental Health/Substance-Related and Addictive Disorders Designee, who is
responsible for coordinating your care or through other pathways as described in the program
introductions. Any decision to participate in such a program or service is at the discretion of the Covered
Person and is not mandatory.
13. Neurodevelopmental Disorders - Autism Spectrum Disorder Services
Psychiatric services for Autism Spectrum Disorder that are both of the following:

Provided by or under the direction of an experienced psychiatrist and/or an experienced licensed
psychiatric provider.

Focused on treating maladaptive/stereotypic behaviors that are posing danger to self, others and
property, and impairment in daily functioning.
Certain services require prior authorization. Please refer to your Schedule of Benefits under the heading
authorization.
This section describes only the psychiatric component of treatment for Autism Spectrum Disorder.
Medical treatment of Autism Spectrum Disorder is a Covered Health Service for which Benefits are
available under the applicable medical Covered Health Services categories in this Policy.


Treatment planning.


Referral services.


IEXPOL.I.15.CT
17






Enhanced Autism Spectrum Disorder services that are focused on educational/behavioral intervention
that are habilitative in nature and that are backed by credible research demonstrating that the services or
supplies have a measurable and beneficial effect on health outcomes. Benefits are provided for intensive
behavioral therapies (educational/behavioral services that are focused on primarily building skills and
capabilities in communication, social interaction and learning such as Applied Behavioral Analysis (ABA)).
14. Pharmaceutical Products - Outpatient
Pharmaceutical Products that are administered on an outpatient basis in a Hospital, Alternate Facility,
Physician's office, or in a Covered Person's home.
Benefits under this section are provided only for Pharmaceutical Products which, due to their
characteristics (as determined by us), must typically be administered or directly supervised by a qualified
provider or licensed/certified health professional. Benefits under this section do not include medications
that are typically available by prescription order or refill at a pharmacy.
If you require certain Pharmaceutical Products, including specialty Pharmaceutical Products, we will direct
you to a Designated Dispensing Entity with whom we have an arrangement to provide those
Pharmaceutical Products. Such Dispensing Entities may include an outpatient pharmacy, specialty
pharmacy, Home Health Agency provider, Hospital-affiliated pharmacy or hemophilia treatment center
contracted pharmacy.
If you/your provider are directed to a Designated Dispensing Entity and you/your provider choose not to
obtain your Pharmaceutical Product from a Designated Dispensing Entity, Network Benefits are not
available for that Pharmaceutical Product.
Certain Pharmaceutical Products are subject to step therapy requirements. This means that in order to
receive Benefits for such Pharmaceutical Products, you are required to use a different Pharmaceutical
Product and/or prescription drug product first. You may determine whether a particular 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.
We may have certain programs in which you may receive an enhanced or reduced Benefit based on your
actions such as adherence/compliance to medication or treatment regimens and/or participation in health
management programs. You may access information on these programs through the Internet at
www.myuhc.com or by calling Customer Care at the telephone number on your ID card.
IEXPOL.I.15.CT
18
15. Physician Fees for Surgical and Medical Services
Physician fees for surgical procedures and other medical care received on an outpatient or inpatient basis
in a Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility or Alternate Facility, or for Physician
house calls.
16. Physician's Office Services - Sickness and Injury
Services provided in a Physician's office for the diagnosis and treatment of a Sickness or Injury. Benefits
are provided under this section regardless of whether the Physician's office is free-standing, located in a
clinic or located in a Hospital.
Covered Health Services include medical education services that are provided in a Physician's office by
appropriately licensed or registered healthcare professionals when both of the following are true:

Education is required for a disease in which patient self-management is an important component of
treatment.

There exists a knowledge deficit regarding the disease which requires the intervention of a trained
health professional.
Covered Health Services include genetic counseling. Benefits are available for Genetic Testing which is
ordered by the Physician and authorized in advance by us.
Benefits under this section include allergy testing and injections, corneal pachymetry and treatment for
diseases and abnormalities of the eye.
Covered Health Services for preventive care provided in a Physician's office are described under
Preventive Care Services.
When a test is performed or a sample is drawn in the Physician's office and then sent outside the
Physician's office for analysis or testing, Benefits for lab, radiology/X-rays and other diagnostic services
that are performed outside the Physician's office are described in Lab, X-ray and Diagnostics - Outpatient.
17. Pregnancy - Maternity Services
Benefits for Pregnancy include all maternity-related medical services for prenatal care, postnatal care,
delivery and any related complications.
Both before and during a Pregnancy, Benefits include the services of a genetic counselor when provided
or referred by a Physician. These Benefits are available to all Covered Persons in the immediate family.
Covered Health Services include related tests and treatment.
We also have special prenatal programs to help during Pregnancy. They are completely voluntary and
there is no extra cost for participating in the program. To sign up, you should notify us during the first
trimester, but no later than one month prior to the anticipated childbirth. It is important that you notify us
regarding your Pregnancy. Your notification will open the opportunity to become enrolled in prenatal
programs designed to achieve the best outcomes for you and your baby.
We will pay Benefits for an Inpatient Stay of at least:

48 hours for the mother and newborn child following a normal vaginal delivery.

96 hours for the mother and newborn child following a cesarean section delivery.
If the mother agrees, the attending provider may discharge the mother and/or the newborn child earlier
than these minimum time frames.
If discharge occurs earlier than these timeframes, we will pay Benefits for a follow-up visit within 48 hours
of discharge and an additional follow-up visit within seven days of discharge.
Follow-up services will include, but not limited to, the following:

Physical assessment of the newborn.
IEXPOL.I.15.CT
19

Parent education.

Assistance and training in breast or bottle feeding.

Assessment of the home support system.

Performance of any medically necessary and appropriate clinical tests.
Follow-up services must be consistent with protocols and guidelines developed by attending providers or
by national pediatric, obstetric and nursing professional organizations. Follow-up services must be
provided by a qualified health care personnel trained in post partum maternal and newborn pediatric care.
18. Preventive Care Services
Preventive care services provided on an outpatient basis at a Physician's office, an Alternate Facility or a
Hospital encompass medical services that have been demonstrated by clinical evidence to be safe and
effective in either the early detection of disease or in the prevention of disease, have been proven to have
a beneficial effect on health outcomes and include the following as required under applicable law:

Evidence-based items or services that have in effect a rating of "A" or "B" in the current
recommendations of the United States Preventive Services Task Force including blood lead
screening and risk assessments.

Immunizations that have in effect a recommendation from the Advisory Committee on
Immunization Practices of the Centers for Disease Control and Prevention.

With respect to infants, children and adolescents, evidence-informed preventive care and
screenings provided for in the comprehensive guidelines supported by the Health Resources and
Services Administration.

With respect to women, such additional preventive care and screenings as provided for in
comprehensive guidelines supported by the Health Resources and Services Administration.
Benefits defined under the Health Resources and Services Administration (HRSA) requirement
include the cost of renting one breast pump per Pregnancy in conjunction with childbirth. Breast
pumps must be ordered by or provided by a Physician. You can obtain additional information on
how to access Benefits for breast pumps by calling Customer Care at the telephone number on
your ID card.
If more than one breast pump can meet your needs, Benefits are available only for the most cost
effective pump. We will determine the following:

Which pump is the most cost effective.

Whether the pump should be purchased or rented.

Duration of a rental.

Timing of an acquisition.
19. Prosthetic Devices
External prosthetic devices that replace a limb or a body part, limited to:

Artificial arms, legs, feet and hands.

Artificial face, eyes, ears and nose.

Breast prosthesis as required by the Women's Health and Cancer Rights Act of 1998. Benefits
include mastectomy bras and lymphedema stockings for the arm.
Benefits under this section are provided only for external prosthetic devices and do not include any device
IEXPOL.I.15.CT
20
If more than one prosthetic device can meet your functional needs, Benefits are available only for the
prosthetic device that meets the minimum specifications for your needs. If you purchase a prosthetic
device that exceeds these minimum specifications, we will pay only the amount that we would have paid
for the prosthetic that meets the minimum specifications, and you will be responsible for paying any
difference in cost.
The prosthetic device must be ordered or provided by, or under the direction of a Physician.

There are no Benefits for repairs due to misuse, malicious damage or gross neglect.

There are no Benefits for replacement due to misuse, malicious damage, gross neglect or for lost
or stolen prosthetic devices.
20. Reconstructive Procedures
Reconstructive procedures when the primary purpose of the procedure is either to treat a medical
condition or to improve or restore physiologic function. Reconstructive procedures include surgery or
other procedures which are associated with an Injury, Sickness or Congenital Anomaly. The primary
result of the procedure is not a changed or improved physical appearance.
Cosmetic Procedures are excluded from coverage. Procedures that correct an anatomical Congenital
Anomaly without improving or restoring physiologic function are considered Cosmetic Procedures. The
fact that a Covered Person may suffer psychological consequences or socially avoidant behavior as a
result of an Injury, Sickness or Congenital Anomaly does not classify surgery (or other procedures done
to relieve such consequences or behavior) as a reconstructive procedure.
Please note that Benefits for reconstructive procedures include breast reconstruction following a
mastectomy, and reconstruction of the non-affected breast to achieve symmetry. Other services required
by the Women's Health and Cancer Rights Act of 1998, including breast prostheses and treatment of
complications, are provided in the same manner and at the same level as those for any other Covered
Health Service. You can contact us at the telephone number on your ID card for more information about
Benefits for mastectomy-related services.
21. Rehabilitation Services - Outpatient Therapy
Short-term outpatient rehabilitation services (including habilitative services), limited to:

Physical therapy.

Occupational therapy.

Speech therapy.

Pulmonary rehabilitation therapy.

Cardiac rehabilitation therapy.

Post-cochlear implant aural therapy.

Cognitive rehabilitation therapy.
Rehabilitation services must be performed by a Physician or by a licensed therapy provider. Benefits
under this section include rehabilitation services provided in a Physician's office or on an outpatient basis
at a Hospital or Alternate Facility.
Benefits can be denied or shortened for Covered Persons who are not progressing in goal-directed
rehabilitation services or if rehabilitation goals have previously been met.
Speech, physical or occupational therapy is Covered for the treatment of autism spectrum disorders as
set forth by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders
to the extent such services are a covered benefit for other diseases and conditions under this policy.
IEXPOL.I.15.CT
21
Habilitative Services
Benefits are provided for habilitative services provided on an outpatient basis for Covered Persons with a
congenital, genetic, or early acquired disorder when both of the following conditions are met:

The treatment is administered by a licensed speech-language pathologist, licensed audiologist,
licensed occupational therapist, licensed physical therapist, Physician, licensed nutritionist,
licensed social worker or licensed psychologist.

The initial or continued treatment must be proven and not Experimental or Investigational.
Benefits for habilitative services do not apply to those services that are solely educational in nature or
otherwise paid under state or federal law for purely educational services. Custodial Care, respite care,
day care, therapeutic recreation, vocational training and residential treatment are not habilitative services.
A service that does not help the Covered Person to meet functional goals in a treatment plan within a
prescribed time frame is not a habilitative service. When the Covered Person reaches his/her maximum
level of improvement or does not demonstrate continued progress under a treatment plan, a service that
was previously habilitative is no longer habilitative.
We may require that a treatment plan be provided, request medical records, clinical notes, or other
necessary data to allow us to substantiate that initial or continued medical treatment is needed and that
the Covered Person's condition is clinically improving as a result of the habilitative service. When the
treating provider anticipates that continued treatment is or will be required to permit the Covered Person
to achieve demonstrable progress, we may request a treatment plan consisting of diagnosis, proposed
treatment by type, frequency, anticipated duration of treatment, the anticipated goals of treatment, and
how frequently the treatment plan will be updated.
For purposes of this benefit, the following definitions apply:

"Habilitative services" means occupational therapy, physical therapy and speech therapy
prescribed by the Covered Person's treating Physician pursuant to a treatment plan to develop a
function not currently present as a result of a congenital, genetic, or early acquired disorder.

A "congenital or genetic disorder" includes, but is not limited to, hereditary disorders.

An "early acquired disorder" refers to a disorder resulting from Sickness, Injury, trauma or some
other event or condition suffered by a Covered Person prior to that Covered Person developing
functional life skills such as, but not limited to, walking, talking, or self-help skills.
Other than as described under Habilitative Services above, please note that we will pay Benefits for
speech therapy for the treatment of disorders of speech, language, voice, communication and auditory
processing only when the disorder results from Injury, stroke, cancer, Congenital Anomaly, or Autism
Spectrum Disorder. We will pay Benefits for cognitive rehabilitation therapy only when Medically
Necessary following a post-traumatic brain Injury or cerebral vascular accident.
22. Scopic Procedures - Outpatient Diagnostic and Therapeutic
Diagnostic and therapeutic scopic procedures and related services received on an outpatient basis at a
Hospital or Alternate Facility or in a Physician's office.
Diagnostic scopic procedures are those for visualization, biopsy and polyp removal. Examples of
diagnostic scopic procedures include colonoscopy, sigmoidoscopy and endoscopy.
Please note that Benefits under this section do not include surgical scopic procedures, which are for the
purpose of performing surgery. Benefits for surgical scopic procedures are described under Surgery Outpatient. Examples of surgical scopic procedures include arthroscopy, laparoscopy, bronchoscopy and
hysteroscopy.

IEXPOL.I.15.CT
22

Physician services for radiologists, anesthesiologists and pathologists. (Benefits for all other
Physician services are described under Physician Fees for Surgical and Medical Services.)
When these services are performed for preventive screening purposes, Benefits are described under
Preventive Care Services.
Included under this section is coverage for colorectal cancer screenings, including, but not limited to
annual fecal occult blood test, colonoscopy and flexible sigmoidoscopy/radiologic imaging in accordance
with the recommendations established by the American Cancer Society. There is no cost share when
more than 1 colonoscopy is ordered in a policy year.
23. Skilled Nursing Facility/Inpatient Rehabilitation Facility Services
Services and supplies provided during an Inpatient Stay in a Skilled Nursing Facility or Inpatient
Rehabilitation Facility. Benefits are available for:

Supplies and non-Physician services received during the Inpatient Stay.

Room and board in a Semi-private Room (a room with two or more beds).

Please note that Benefits are available only if both of the following are true:

If the initial confinement in a Skilled Nursing Facility or Inpatient Rehabilitation Facility was or will
be a cost effective alternative to an Inpatient Stay in a Hospital.

You will receive skilled care services that are not primarily Custodial Care.
Skilled care is skilled nursing, skilled teaching and skilled rehabilitation services when all of the following
are true:

It must be delivered or supervised by licensed technical or professional medical personnel in order
to obtain the specified medical outcome, and provide for the safety of the patient.

It is ordered by a Physician.

It is not delivered for the purpose of assisting with activities of daily living, including dressing,
feeding, bathing or transferring from a bed to a chair.

It requires clinical training in order to be delivered safely and effectively.
We will determine if Benefits are available by reviewing both the skilled nature of the service and the need
for Physician-directed medical management. A service will not be determined to be "skilled" simply
because there is not an available caregiver.
Benefits can be denied or shortened for Covered Persons who are not progressing in goal-directed
rehabilitation services or if discharge rehabilitation goals have previously been met.
24. Substance-Related and Addictive Disorders Services
Substance-Related and Addictive Disorders Services include those received on an inpatient basis in a
Hospital or an Alternate Facility, and those received on an outpatient basis in a provider's office or at an
Alternate Facility. Certain Substance-Related and Addictive Disorders services require prior authorization.
Please refer to your Schedule of Benefits under the heading Covered Health Services which Require
Prior Authorization for a detail list of services that require prior authorization.


Treatment planning.
IEXPOL.I.15.CT
23


Referral services.








Special-Related and Addictive Disorders Programs and Services
Addictive Disorders Designee may become available to you as a part of your Substance-Related and
Addictive Disorders Services Benefit. The Substance-Related and Addictive Disorders Services Benefits
and financial requirements assigned to these programs or services are based on the designation of the
program or service to inpatient, Partial Hospitalization/Day Treatment, Intensive Outpatient Treatment,
outpatient or a Transitional Care category of Benefit use. Special programs or services provide access to
services that are beneficial for the treatment of your substance-related and addictive disorders which may
not otherwise be covered under this Policy. You must be referred to such programs through the Mental
Health/Substance-Related and Addictive Disorders Designee, who is responsible for coordinating your
care or through other pathways as described in the program introductions. Any decision to participate in
such a program or service is at the discretion of the Covered Person and is not mandatory.
25. Surgery - Outpatient
Surgery and related services received on an outpatient basis at a Hospital or Alternate Facility or in a
Physician's office.
Benefits under this section include certain scopic procedures. Examples of surgical scopic procedures
include arthroscopy, laparoscopy, bronchoscopy and hysteroscopy.
Examples of surgical procedures performed in a Physician's office are mole removal and ear wax
removal.


IEXPOL.I.15.CT
24

Sterilization
Please refer to our provider directory located on our website at www.myuhc.com for assistance with
identifying the different types of facilities.
26. Therapeutic Treatments - Outpatient
Therapeutic treatments received on an outpatient basis at a Hospital or Alternate Facility or in a
Physician's office, including dialysis (both hemodialysis and peritoneal dialysis), intravenous
chemotherapy or other intravenous infusion therapy and radiation oncology.
Covered Health Services include medical education services that are provided on an outpatient basis at a
Hospital or Alternate Facility by appropriately licensed or registered healthcare professionals when both
of the following are true:

Education is required for a disease in which patient self-management is an important component of
treatment.

There exists a knowledge deficit regarding the disease which requires the intervention of a trained
health professional.

The facility charge and the charge for related supplies and equipment.

Physician services for anesthesiologists, pathologists and radiologists. Benefits for other Physician
services are described under Physician Fees for Surgical and Medical Services.

Sleep studies.
27. Transplantation Services
Organ and tissue transplants when ordered by a Physician. Benefits are available for transplants when
the transplant meets the definition of a Covered Health Service, and is not an Experimental or
Investigational or Unproven Service.
Examples of transplants for which Benefits are available include bone marrow, heart, heart/lung, lung,
kidney, kidney/pancreas, liver, liver/small bowel, pancreas, small bowel and cornea.
Donor costs that are directly related to organ removal are Covered Health Services for which Benefits are
payable through the organ recipient's coverage under this Policy.
Human leukocyte antigen testing or histocompatibility locus antigen testing for A, B and DR antigens
(testing to determine the compatibility for bone marrow transplants). The bone marrow testing must be
performed at a facility certified under the federal Clinical Laboratory Improvement Act and accredited by
the American Society for Histocompatibility and Immunogenetics. Enrollees must register for the National
Marrow Donor Program when being tested.
We have specific guidelines regarding Benefits for transplant services. Contact us at the telephone
number on your ID card for information about these guidelines.
Transportation, Lodging and Meal Expenses for Transplants
Expenses for transplantation, lodging, and meals for the transplant recipient and his or her companion are
reimbursable per transplant episode.
A “transplant episode” is the time from the initial evaluation for the transplant until 90 days after the
recipient is discharged from the transplant facility or until the recipient is cleared to return home,
whichever is sooner.
The transplant facility must be more than 300 miles from the transplant recipient’s home for this
reimbursement to apply.
IEXPOL.I.15.CT
25

Transportation costs incurred for travel to and from the transplant facility for the transplant recipient
and one other individual accompanying the recipient are covered.

If air transportation is chosen, coverage includes round trip transportation for the transplant
recipient and one other individual accompanying the recipient up to two round trips per person.

If travel occurs via automobile, mileage will be reimbursed based on the federal Internal Revenue
Code mileage reimbursement rate at the time the travel was undertaken for a maximum of one
round trip from the transplant recipient’s home to the transplant facility.

Transportation, lodging and meal receipts must be submitted to us at the appropriate address listed
in the information you receive from us when authorizing this reimbursement.

There is no coverage for the following expenses:

Any expenses for anyone other than the transplant recipient and the designated traveling
companion.

Any expenses other than the transportation, lodging and meals described in this provision.

Local transportation costs while at the transplant facility.

Rental car costs.
28. Urgent Care Center Services
Covered Health Services received at an Urgent Care Center. When services to treat urgent health care
needs are provided in a Physician's office, Benefits are available as described under Physician's Office
Services - Sickness and Injury.
Additional Benefits Required By Connecticut Law
29. Craniofacial Disorders
Benefits for medically necessary orthodontic processes and appliances for the treatment of craniofacial
disorders for Covered Persons eighteen years of age or younger when prescribed by a craniofacial team
recognized by the American Cleft Palate Craniofacial Association. This does not provide coverage for
cosmetic surgery.
30. Dental Services - Accident Only *
Surgery, general anesthesia, nursing and associated Hospital or Alternative Facility services provided in
conjunction with inpatient, outpatient or one-day dental services when the dentist or oral surgeon and the
Physician determine that the services are medically necessary for the treatment of either of the following
types of patient:

A person who is determined by a dentist, in conjunction with a Physician who specializes in primary
care, to have a dental condition of significant dental complexity that it requires certain dental
procedures to be performed in a Hospital or Alternate Facility.

A person who has a developmental disability, as determined by a Physician who specializes in
primary care that places the person at serious risk.
* Refer to Section 10: Pediatric Dental Services for additional dental coverage information.
31. Developmental Needs of Children & Youth with Cancer
Neuropsychological testing ordered by a licenses physician, to assess the extent of any cognitive or
developmental delays in children due to chemotherapy or radiation treatment.
IEXPOL.I.15.CT
26
32. Early Intervention Services
Coverage for early intervention services provided as part of an individualized family services plan as
defined by Connecticut law for a child from birth until the child's third birthday.
Early intervention services are not subject to co-insurance, copayments, deductibles or other out-ofpocket expenses, regardless of whether the provider is a Network or Non-Network provider.
33. Infertility Services
Services for the treatment of infertility when provided by or under the direction of a Physician.
For the purpose of this benefit, infertility is defined as the condition of a presumably health individual who
is unable to conceive or produce conception or sustain a successful pregnancy during a one-year period.
Coverage must be provided for the expense for the diagnosis and treatment of infertility, including but not
limited to:

Ovulation induction.

Intrauterine insemination.

In-vitro fertilization.

Uterine embryo lavage.

Embryo transfer.

Gamete intra-fallopian transfer (GIFT).

Zygote intra-fallopian transfer (ZIFT).

Low tubal ovum transfer.
Benefits for infertility are limited to the following:

Coverage is limited to individuals under the age of 40;

Ovulation induction is limited to a lifetime maximum benefit of four cycles;

Intrauterine insemination is limited to a lifetime maximum benefit of three cycles;

IVF, GIFT, ZIFT and low tubal ovum transfer are limited to a lifetime maximum of two cycles, with
no more than two embryo implantations per cycle;

IVF, GIFT, ZIFT and low tubal ovum transfer are limited to individuals who have not been able to
conceive, produce conception or sustain a successful pregnancy through less expensive and
medically viable infertility treatments unless their Physician determines that such treatment is likely
to be unsuccessful;

Covered Health Services must be performed at facilities that conform to the standards of the
American Society of Reproductive Medicine or the Society of Reproductive Endocrinology and
Infertility.
34. Lyme Disease Services
Coverage for Lyme disease treatment, including but not limited to up to 30 days of intravenous antibiotic
therapy and/or sixty days of oral antibiotic therapy and further treatment will be provided if recommended.
IEXPOL.I.15.CT
27
35. Medical Foods
Coverage for amino acid modified preparations and low protein modified food products for the treatment
of inherited metabolic diseases which are prescribed for the treatment of inherited metabolic diseases
and are administered under the direction of a Physician.
In addition, coverage must be provided for specialized formulas when they are medically necessary for
the treatment of a disease or condition and are administered under the direction of a Physician.
Coverage for specialized formulas when such specialized formulas are for the treatment of a disease or
condition and are administered under the direction of a Physician.
Inherited metabolic diseases - a disease for which newborn screening is required under section 19a-55 of
the general statutes of Connecticut and cystic fibrosis.
Amino acid modified preparation - a product intended for the dietary treatment of an inherited metabolic
disease under the direction of a Physician.
Specialized formula - a nutritional formula for children up to the age of twelve years of age that is exempt
from the general requirements for nutritional labeling under the statutory and regulatory guidelines of the
federal Food and Drug Administration and is intended for use solely under medical supervision in the
dietary management of specific diseases.
36. Nutritional Counseling
Nutritional Counseling is a Covered Health Service for illnesses requiring therapeutic dietary monitoring,
including the diagnosis of obesity. In addition, the services must be prescribed by a licensed health care
professional and provided by a certified, registered or licensed health care professional in a physician's
office or outpatient facility.
37. Ostomy Supplies
Benefits for medically necessary appliances and supplies relating to an ostomy include, but are not
limited to, the following:

Collection devices

Pouches, face plates and belts.

Irrigation equipment and supplies such as sleeves, bags and ostomy irrigation catheters.

Skin barriers and skin protectors.
Benefits are not available for deodorants, filters, lubricants, tape, appliance cleaners, adhesive, adhesive
remover, or other items not listed above.
38. Pain Management
Covered Health Services received by a pain management specialist for pain treatment which may include
all means medically necessary to make a diagnosis and develop a treatment plan including the use of
necessary medications and procedures.
39. Wound Care Supplies
Wound care supplies for the treatment of epidermolysis bullosa when administered under the direction of
a Physician. Epidermolysis bullosa is a rare inherited genetic disorder caused by a mutation in the keratin
gene. The disorder is characterized by the presence of extremely fragile skin and recurrent blister
formation, resulting from minor mechanical friction or trauma. The resulting wounds require continuous
treatment.
IEXPOL.I.15.CT
28
40. Wigs
Wigs and other scalp hair prosthesis for a Covered Person who suffers hair loss as a result of
chemotherapy when prescribed by a licensed oncologist.
IEXPOL.I.15.CT
29
Section 2: Exclusions and Limitations
How We Use Headings in this Section
To help you find specific exclusions more easily, we use headings (for example A. Alternative Treatments
below). The headings group services, treatments, items, or supplies that fall into a similar category. Actual
exclusions appear underneath headings. A heading does not create, define, modify, limit or expand an
exclusion. All exclusions in this section apply to you.
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 this
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 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."
A. Alternative Treatments
1.
Acupressure and acupuncture. This exclusion does not apply to acupressure and acupuncture
services for which Benefits are available as described under Pain Management in Section 1:
Covered Health Services.
2.
Aromatherapy.
3.
Hypnotism.
4.
Massage therapy.
5.
Rolfing.
6.
Art therapy, music therapy, dance therapy, 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 non-manipulative
osteopathic care for which Benefits are provided as described in Section 1: Covered Health
Services.
B. Dental
Please Note: This exclusion does not apply to Pediatric Dental Services. Refer to Section 10:
Pediatric Dental Services for coverage information.
IEXPOL.I.15.CT
30
1.
Dental care (which includes dental X-rays, supplies and appliances and all associated expenses,
including hospitalizations and anesthesia).
This exclusion does not apply to accident-related dental services for which Benefits are provided as
described under Craniofacial Disorders and Dental Services - Accident Only in Section 1: Covered
Health Services.
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 this Policy, limited to:

Transplant preparation.

Prior to the initiation of immunosuppressive drugs.

The direct treatment of acute traumatic Injury, cancer or cleft palate.
Dental care that is required to treat the effects 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.
2.
Preventive care, diagnosis, treatment of or related to the teeth, jawbones or gums. Examples
include:

Extraction, restoration and replacement of teeth.

Medical or surgical treatments of dental conditions.

Services to improve dental clinical outcomes.
This exclusion does not apply to accident-related dental services for which Benefits are provided as
described under Craniofacial Disorders and Dental Services - Accident Only in Section 1: Covered
Health Services.
3.
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 Craniofacial
Disorders and Dental Services - Accident Only in Section 1: Covered Health Services.
4.
Dental braces (orthodontics).
5.
Treatment of congenitally missing, malpositioned or supernumerary teeth, even if part of a
Congenital Anomaly.
C. Devices, Appliances and Prosthetics
1.
Devices used specifically as safety items or to affect performance in sports-related activities.
2.
Orthotic appliances that straighten or re-shape a body part. Examples include foot orthotics and
some types of braces, including over-the-counter orthotic braces.
3.
Cranial banding.
4.
The following items are excluded, even if prescribed by a Physician:
5.

Blood pressure cuff/monitor.

Enuresis alarm.

Non-wearable external defibrillator.

Trusses.

Ultrasonic nebulizers.
Devices and computers to assist in communication and speech.
IEXPOL.I.15.CT
31
6.
Oral appliances for snoring.
7.
Repairs to prosthetic devices due to misuse, malicious damage or gross neglect.
8.
Replacement of prosthetic devices due to misuse, malicious damage or gross neglect or to replace
lost or stolen items.
D. Drugs
1.
Prescription drug products for outpatient use that are filled by a prescription order or refill.
2.
Self-injectable medications. This exclusion does not apply to drugs for the treatment of diabetes
and medications which, due to their characteristics (as determined by us), must typically be
administered or directly supervised by a qualified provider or licensed/certified health professional
in an outpatient setting.
3.
Non-injectable medications given in a Physician's office. This exclusion does not apply to noninjectable medications that are required in an Emergency and consumed in the Physician's office.
4.
Over-the-counter drugs and treatments.
5.
Growth hormone therapy.
6.
Benefits for Pharmaceutical Products for the amount dispensed (days' supply or quantity limit)
which exceeds the supply limit.
E. Experimental or Investigational or Unproven Services
Experimental or Investigational and Unproven Services and all services related to Experimental or
Investigational and Unproven Services are excluded. The fact that an Experimental or
Investigational or Unproven Service, treatment, device or pharmacological regimen is the only
available treatment for a particular condition will not result in Benefits if the procedure is considered
to be Experimental or Investigational or Unproven in the treatment of that particular 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 Section 1: Covered Health Services.
F. Foot Care
1.
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 Section 1: Covered Health Services.
2.
Nail trimming, cutting, or debriding.
3.
Hygienic and preventive maintenance foot care. 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.
4.
Treatment of flat feet.
5.
Treatment of subluxation of the foot.
6.
Shoes.
7.
Shoe orthotics.
8.
Shoe inserts.
9.
Arch supports.
IEXPOL.I.15.CT
32
G. Medical Supplies
1.
Prescribed or non-prescribed medical supplies and disposable supplies. Examples include:

Compression stockings.

Ace bandages.

Gauze and dressings.

Urinary catheters.

Ostomy supplies.
This exclusion does not apply to:
2.

Disposable supplies necessary for the effective use of Durable Medical Equipment for which
Benefits are provided as described under Durable Medical Equipment in Section 1: Covered
Health Services.

Diabetic supplies for which Benefits are provided as described under Diabetes Services in
Section 1: Covered Health Services.
Tubings and masks except when used with Durable Medical Equipment as described under
Durable Medical Equipment in Section 1: Covered Health Services.
H. Mental Health
In addition to all other exclusions listed in this Section 2: Exclusions and Limitations, the exclusions listed
directly below apply to services described under Mental Health Services in Section 1: Covered Health
Services.
1.
Services performed in connection with conditions not classified in the current edition of the
Diagnostic and Statistical Manual of the American Psychiatric Association.
2.
Mental Health Services as treatments for R and T code conditions as listed within the current
edition of the Diagnostic and Statistical Manual of the American Psychiatric Association.
3.
Treatments for the primary diagnoses of learning disabilities.
4.
Caffeine-related disorders.
5.
Educational/behavioral services that are focused on primarily building skills and capabilities in
communication, social interaction and learning.
6.
Tuition for or services that are school-based for children and adolescents under the Individuals with
Disabilities Education Act.
7.
Learning, motor disorders and primary communication disorders as defined in the current edition of
the Diagnostic and Statistical Manual of the American Psychiatric Association.
8.
Intellectual disabilities and autism spectrum disorder as a primary diagnosis defined in the current
edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Benefits
for autism spectrum disorder as a primary diagnosis are described under Neurodevelopmental
Disorders - Autism Spectrum Disorder Services in Section 1: Covered Health Services.
9.
Mental Health Services as a treatment for other conditions that may be a focus of clinical attention
as listed in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric
Association.
10.
All unspecified disorders in the current edition of the Diagnostic and Statistical Manual of the
American Psychiatric Association.
11.
Health services and supplies that do not meet the definition of a Covered Health Service - see the
definition in Section 8: Defined Terms. Covered Health Services are those health services,
IEXPOL.I.15.CT
33
including services, supplies, or Pharmaceutical Products, which we determine to be all of the
following:

Medically Necessary.

Described as a Covered Health Service in this Policy under Section 1: Covered Health
Services and in the Schedule of Benefits.

Not otherwise excluded in this Policy under Section 2: Exclusions and Limitations.
I. Neurodevelopmental Disorders - Autism Spectrum Disorder
directly below apply to services described under Neurodevelopmental Disorders - Autism Spectrum
Disorder Services in Section 1: Covered Health Services.
1.
Services as treatments of sexual dysfunction and feeding disorders as listed in the current edition
of the Diagnostic and Statistical Manual of the American Psychiatric Association.
2.
Any treatments or other specialized services designed for Autism Spectrum Disorder that are not
backed by credible research demonstrating that the services or supplies have a measurable and
beneficial health outcome and therefore considered Experimental or Investigational or Unproven
Services.
3.
Intellectual disability as the primary diagnosis defined in the current edition of the Diagnostic and
Statistical Manual of the American Psychiatric Association.
4.
5.
Learning, motor disorders and communication disorders as defined in the current edition of the
Diagnostic and Statistical Manual of the American Psychiatric Association and which are not a part
of Autism Spectrum Disorder.
6.
7.
8.
following:



J. Nutrition
1.
Individual and group nutritional counseling. This exclusion does not apply to medical nutritional
education services that are provided by appropriately licensed or registered health care
professionals when both of the following are true:

Nutritional education is required for a disease in which patient self-management is an
important component of treatment.

There exists a knowledge deficit regarding the disease which requires the intervention of a
trained health professional.
2.
Enteral feedings, even if the sole source of nutrition, except as described under Medical Foods in
IEXPOL.I.15.CT
34
3.
Infant formula, except specialized formulas as described under Medical Foods in Section 1:
Covered Health Services, and donor breast milk.
4.
Nutritional or cosmetic therapy using high dose or mega quantities of vitamins, minerals or
elements and other nutrition-based therapy. Examples include supplements, electrolytes and foods
of any kind (including high protein foods and low carbohydrate foods).
K. Personal Care, Comfort or Convenience
1.
Television.
2.
Telephone.
3.
Beauty/barber service.
4.
Guest service.
5.
Supplies, equipment and similar incidental services and supplies for personal comfort. Examples
include:

Air conditioners, air purifiers and filters and dehumidifiers.

Batteries and battery chargers.

Breast pumps. This exclusion does not apply to breast pumps for which Benefits are
provided under the Health Resources and Services Administration (HRSA) requirement.

Car seats.

Chairs, bath chairs, feeding chairs, toddler chairs, chair lifts and recliners.

Exercise equipment.

Home modifications such as elevators, handrails and ramps.

Hot tubs.

Humidifiers.

Jacuzzis.

Mattresses.

Medical alert systems.

Motorized beds.

Music devices.

Personal computers.

Pillows.

Power-operated vehicles.

Radios.

Saunas.

Stair lifts and stair glides.

Strollers.

Safety equipment.

Treadmills.

Vehicle modifications such as van lifts.

Video players.
IEXPOL.I.15.CT
35

Whirlpools.
L. Physical Appearance
1.
2.
Cosmetic Procedures. See the definition in Section 8: Defined Terms. 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.

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 breast implant if the earlier breast implant was performed as a
Cosmetic Procedure. Note: Replacement of an existing breast implant is considered reconstructive
if the initial breast implant followed mastectomy. See Reconstructive Procedures in Section 1:
The exception to this is the removal of a breast implant which was implanted on or prior to July 1,
1994, without regard to the purpose of such implantation.
3.
Treatment of benign gynecomastia (abnormal breast enlargement in males).
4.
Physical conditioning programs such as athletic training, body-building, exercise, fitness, flexibility
and diversion or general motivation.
5.
Weight loss programs whether or not they are under medical supervision. Weight loss programs for
medical reasons are also excluded.
6.
Wigs, except as required for hair loss due to chemotherapy as described in Section 1: Covered
Health Services.
M. Procedures and Treatments
1.
Excision or elimination of hanging skin on any part of the body. Examples include plastic surgery
procedures called abdominoplasty or abdominal panniculectomy and brachioplasty.
2.
Medical and surgical treatment of excessive sweating (hyperhidrosis).
3.
Medical and surgical treatment for snoring, except when provided as a part of treatment for
documented obstructive sleep apnea.
4.
Rehabilitation services to improve general physical condition that are provided to reduce potential
risk factors, where significant therapeutic improvement is not expected, including routine, long-term
or maintenance/preventive treatment.
5.
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 Disorder.
6.
Outpatient cognitive rehabilitation therapy except as Medically Necessary following a posttraumatic brain Injury or cerebral vascular accident.
7.
Psychosurgery.
8.
Physiological modalities and procedures that result in similar or redundant therapeutic effects when
performed on the same body region during the same visit or office encounter.
9.
Biofeedback.
IEXPOL.I.15.CT
36
10.
The following services for the diagnosis and treatment of TMJ: surface electromyography; Doppler
analysis; vibration analysis; computerized mandibular scan or jaw tracking; craniosacral therapy;
orthodontics; occlusal adjustment; and dental restorations.
11.
Upper and lower jawbone surgery, orthognathic surgery, and jaw alignment. This exclusion does
not apply to reconstructive jaw surgery required for Covered Persons because of a Congenital
Anomaly, acute traumatic Injury, dislocation, tumors, cancer or obstructive sleep apnea.
12.
Surgical and non-surgical treatment of obesity.
13.
Stand-alone multi-disciplinary smoking cessation programs. These are programs that usually
include health care providers specializing in smoking cessation and may include a psychologist,
social worker or other licensed or certified professional. The programs usually include intensive
psychological support, behavior modification techniques and medications to control cravings.
14.
Breast reduction surgery except as coverage is required by the Women's Health and Cancer
Rights Act of 1998 for which Benefits are described under Reconstructive Procedures in Section 1:
N. Providers
1.
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.
2.
Services performed by a provider with your same legal residence.
3.
Services provided at a free-standing or Hospital-based diagnostic facility without an order written
by a Physician or other provider. Services which are self-directed to a free-standing or Hospitalbased 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.
O. Reproduction
1.
Health services and associated expenses for infertility treatments for Covered Persons over age
40, 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.
2.
Surrogate parenting, donor eggs, donor sperm and host uterus.
3.
The reversal of voluntary sterilization.
4.
Fetal reduction surgery.
P. Services Provided under another Plan
1.
Subject to applicable law: Health services for which other coverage is required by federal, state or
local law to be purchased or provided through other arrangements. Examples include coverage
required by workers' compensation, no-fault auto insurance, or similar legislation.
IEXPOL.I.15.CT
37
If coverage under workers' compensation or similar legislation is optional for you because you
could elect it, or could have it elected for you, Benefits will not be paid for any Injury, Sickness or
Mental Illness that would have been covered under workers' compensation or similar legislation
had that coverage been elected.
2.
Health services for treatment of military service-related disabilities, when you are legally entitled to
other coverage and facilities are reasonably available to you.
3.
Health services while on active military duty.
Q. Substance-Related and Addictive Disorders
directly below apply to services described under Substance-Related and Addictive Disorders Services in
1.
2.
Methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol), Cyclazocine, or their
equivalents.
3.
Educational/behavioral services that are focused on primarily building skills and capabilities in
communication, social interaction and learning.
4.
Substance-induced sexual dysfunction disorders and substance-induced sleep disorders.
5.
Gambling disorders.
6.
7.
following:



R. Transplants
1.
Health services for organ and tissue transplants, except those described under Transplantation
Services in Section 1: Covered Health Services.
2.
Health services connected with the removal of an organ or tissue from you for purposes of a
transplant to another person. (Donor costs that are directly related to organ removal are payable for
a transplant through the organ recipient's Benefits under this Policy.)
3.
Health services for transplants involving permanent mechanical or animal organs.
S. Travel
1.
Health services provided in a foreign country, unless required as Emergency Health Services.
2.
Travel or transportation expenses, even though prescribed by a Physician. Some travel expenses
related to Covered Health Services received from a Designated Facility or Designated Physician
may be reimbursed, as we determine. This exclusion does not apply to ambulance transportation
for which Benefits are provided as described under Ambulance Services in Section 1: Covered
Health Services.
IEXPOL.I.15.CT
38
T. Types of Care
1.
Multi-disciplinary pain management programs provided on an inpatient basis for acute pain or for
exacerbation of chronic pain, unless such treatment is medically necessary and has been ordered
by a pain management specialist.
2.
Custodial Care or maintenance care.
3.
Domiciliary care.
4.
Private Duty Nursing.
5.
Respite care. This exclusion does not apply to respite care that is part of an integrated hospice
care program of services provided to a terminally ill person by a licensed hospice care agency for
which Benefits are provided as described under Hospice Care in Section 1: Covered Health
Services.
6.
Rest cures.
7.
Services of personal care attendants.
8.
Work hardening (individualized treatment programs designed to return a person to work or to
prepare a person for specific work).
U. Vision and Hearing
Please Note: The following vision exclusion does not apply to Pediatric Vision services. Refer to
Section 11: Pediatric Vision Care Services for coverage information.
1.
Purchase cost and fitting charge for eyeglasses and contact lenses.
2.
Routine vision examinations, including refractive examinations to determine the need for vision
correction.
3.
Implantable lenses used only to correct a refractive error (such as Intacs corneal implants).
4.
Eye exercise or vision therapy.
5.
Surgery that is intended to allow you to see better without glasses or other vision correction.
Examples include radial keratotomy, laser and other refractive eye surgery.
6.
Purchase cost and associated fitting and testing charges for hearing aids, bone anchored hearing
aids and all other hearing assistive devices.
V. All Other Exclusions
1.
2.
following:
♦
♦
♦
Physical, psychiatric or psychological exams, testing, vaccinations, immunizations or treatments
that are otherwise covered under this Policy when:

Required solely for purposes of school, sports or camp, travel, career or employment,
insurance, marriage or adoption.

Related to judicial or administrative proceedings or orders.
IEXPOL.I.15.CT
39

Conducted for purposes of medical research. 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 Section 1: Covered Health Services.

Required to obtain or maintain a license of any type.
3.
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. This exclusion does not apply to
Covered Persons who are civilians Injured or otherwise affected by war, any act of war, or terrorism
in non-war zones.
4.
Health services received after the date your coverage under this Policy 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 this Policy ended.
5.
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 this Policy.
6.
In the event a non-Network provider waives Copayments, Coinsurance and/or any deductible for a
particular health service, no Benefits are provided for the health service for which the Copayments,
Coinsurance and/or deductible are waived.
7.
Charges in excess of Eligible Expenses or in excess of any specified limitation.
8.
Long term (more than 30 days) storage. Examples include cryopreservation of tissue, blood and
blood products.
9.
Autopsy.
10.
Foreign language and sign language services.
11.
Health services related to a non-Covered Health Service: When a service is not a Covered Health
Service, all services related to that non-Covered Health Service are also excluded. This exclusion
does not apply to services we would otherwise determine to be Covered Health Services if they are
to treat complications that arise from the non-Covered Health Service.
For the purpose of this exclusion, a "complication" is an unexpected or unanticipated condition that
is superimposed on an existing disease and that affects or modifies the prognosis of the original
disease or condition. Examples of a "complication" are bleeding or infections, following a Cosmetic
Procedure, that require hospitalization.
IEXPOL.I.15.CT
40
Section 3: When Coverage Begins and Premiums
How to Enroll
Eligible Persons must complete enrollment and make the required Premium payment, as determined by
the Access Health CT. We will not provide Benefits for health services that you receive before your
effective date of coverage.
If You Are Hospitalized When Your Coverage Begins
If you are an inpatient in a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility on the day
your coverage begins, we will pay Benefits for Covered Health Services that you receive on or after your
first day of coverage related to that Inpatient Stay as long as you receive Covered Health Services in
accordance with the terms of this Policy. These Benefits are subject to any prior carrier's obligations
under state law or contract.
You should notify us of your hospitalization within 48 hours of the day your coverage begins, or as soon
as is reasonably possible. Network Benefits are available only if you receive Covered Health Services
from Network providers.
Who is Eligible for Coverage
The Access Health CT determines who is eligible to enroll under this Policy and who qualifies as a
Dependent.
Eligible Person
Eligible Person refers to a person who meets the eligibility rules established by the Access Health CT.
When an Eligible Person actually enrolls, we refer to that person as a Policyholder. For a complete
definition of Eligible Person and Policyholder, see Section 8: Defined Terms.
Eligible Persons must live within the Service Area, unless otherwise provided by the Access Health CT.
Dependent
Dependent generally refers to the Policyholder's spouse and children. When a Dependent actually
enrolls, we refer to that person as an Enrolled Dependent. For a complete definition of Dependent and
Enrolled Dependent, see Section 8: Defined Terms.
Dependents of an Eligible Person may not enroll unless the Eligible Person is also covered under this
Policy.
When to Enroll and When Coverage Begins
Except as described below, Eligible Persons may not enroll themselves or their Dependents.
Open Enrollment Period
The open enrollment period is the period of time when Eligible Persons can enroll themselves and their
Dependents, as determined by the Access Health CT.
Coverage begins on the date determined by the Access Health CT and identified in this Policy if we
receive the completed enrollment materials and the required Premium.
Special Enrollment Period
An Eligible Person and/or Dependent may also be able to enroll during a special enrollment period, as
determined by the Access Health CT.
IEXPOL.I.15.CT
41
Adding New Dependents
Policyholders may enroll Dependents only as determined by the Access Health CT.
The Policyholder must notify Access Health CT of a new Dependent to be added to this Policy. The
effective date of the Dependent's coverage must follow Access Health CT rules. Additional Premium may
also be required, and it will be calculated from the date determined by Access Health CT.
Premiums
All Premiums are payable on a monthly basis, by the Policyholder. The first Premium is due and payable
on the effective date of this Policy. Subsequent Premiums are due and payable no later than the first day
of the month thereafter that this Policy is in effect.
We will also accept Premium payments from the following third parties:

Ryan White HIV/AIDS Program under title XXVI of the Public Health Service Act.

Indian tribes, tribal organizations or urban Indian organizations.

State and Federal Government programs.
Each Premium is to be paid by you, or a third party identified above, without contribution or
reimbursement by or on behalf of any other third party including, but not limited to, any health care
provider or any health care provider sponsored organization.
Premiums shall not be pro-rated based upon your effective date of coverage. A full month's Premium
shall be charged for the entire month in which the Covered Person's coverage becomes effective.
Misstatement of Age or Tobacco Use
If a Covered Person's age or tobacco use status has been misstated, Benefits may be adjusted based on
the relationship of the Premium paid to the Premium that should have been paid, based on the correct
age or tobacco use status.
Change or Misstatement of Residence
If you change your residence, you must notify Access Health CT of your new residence. Your Premium
will be based on your new residence beginning on the date determined by Access Health CT. If the
change in residence results in the Policyholder no longer living in the Service Area, this Policy will
terminate as described in Section 4: When Coverage Ends.
Grace Period
A grace period of 31 days shall be granted for the payment of any Premium, during which time coverage
under this Policy shall continue in force. If payment is not received within this 31-day grace period,
coverage may be canceled after the 31st day and the Policyholder shall be held liable for the cost of
services received during the grace period. In no event shall the grace period extend beyond the date this
Policy terminates.
We may pay Benefits for Covered Health Services incurred during this 31-day grace period. Any such
Benefit payment is made in reliance on the receipt of the full Premium due from you by the end of the
grace period.
However, if we pay Benefits for any claims during the grace period, and the full Premium is not paid by
the end of the grace period, we will require repayment of all Benefits paid from you or any other person or
organization that received payment on those claims. If repayment is due from another person or
organization, you agree to assist and cooperate with us in obtaining repayment. You are responsible for
repaying us if we are unsuccessful in recovering our payments from these other sources.
If you are receiving an Advance Payment of Tax Credit, as allowed under section 36B of title 26, as
provided for by the Patient Protection and Affordable Care Act (PPACA), we will pay for Covered Health
Services during the 31-day grace period. You are responsible for paying the grace period Premium. If we
IEXPOL.I.15.CT
42
do not receive the Premium payment by the Premium due date, you will have a three month grace period
during which you may pay your Premium and keep your coverage in force. Prior to the last day of the
three month grace period, we must receive all Premiums due for those three months. No claims will be
paid beyond the initial 31-day grace period until all Premiums are paid for the full three month grace
period.
Adjustments to Premiums
We reserve the right to change the schedule of Premiums on January 1st of each calendar year. We shall
give written notice of any change in Premium to the Policyholder at least 31 days prior to the effective
date of the change.
IEXPOL.I.15.CT
43
Section 4: When Coverage Ends
General Information about When Coverage Ends
We may discontinue this Policy and/or all similar policies for the reasons explained in this Policy, as
permitted by law.
Your entitlement to Benefits automatically ends on the date that coverage ends, even if you are
hospitalized or are otherwise receiving medical treatment on that date.
When your coverage ends, we will still pay claims for Covered Health Services that you received before
the date on which your coverage ended. However, once your coverage ends, we will not pay claims for
any health services received after that date (even if the medical condition that is being treated occurred
before the date your coverage ended).
Unless otherwise stated, an Enrolled Dependent's coverage ends on the date the Policyholder's coverage
ends.
Notice of termination of this Policy, including the reason, will be provided to you at least 30 days prior to
the date of termination.
We will refund any Premium paid and not earned due to Policy termination.
This Policy may also terminate due to changes in the actuarial value requirements under state or federal
law. If this Policy terminates for this reason, a new Policy, if available, may be issued to you.
You may keep coverage in force by timely payment of the required Premiums under this Policy or under
any subsequent Coverage you have with us.
This Policy will renew on January 1 of each calendar year. However, we may refuse renewal if either of
the following occur:

We refuse to renew all policies issued on this form, with the same type and level of Benefits, to
residents of the state where you then live, as explained under The Entire Policy Ends below.

There is fraud or intentional misrepresentation made by or with the knowledge of a Covered Person
in filing a claim for Benefits, as explained under Fraud or Intentional Misrepresentation below.
Events Ending Your Coverage
Coverage ends on the earliest of the dates specified below:

The Entire Policy Ends
Your coverage ends on the date this Policy ends. That date will be one of the following:


The date determined by the Access Health CT that this Policy will terminate because the
Policyholder no longer lives in the Service Area.

The date we specify, after we give you 90 days prior written notice, that we will terminate this
Policy because we will discontinue offering and refuse to renew all policies issued on this
form, with the same type and level of benefits, for all residents of the state where you reside.

The date we specify, after we give you and the applicable state authority at least 180 days
prior written notice, that we will terminate this Policy because we will discontinue offering and
refuse to renew all individual policies/certificates in the individual market in the state where
you reside.
You Are No Longer Eligible
Your coverage ends on the date you are no longer eligible to be an Enrolled Dependent, as
determined by the Access Health CT. Please refer to Section 8: Defined Terms for complete
definitions of the terms "Dependent" and "Enrolled Dependent."
IEXPOL.I.15.CT
44

We Receive Notice to End Coverage
Your coverage ends on the date determined by the Access Health CT rules if we receive notice
from the Access Health CT instructing us to end your coverage.
Your coverage ends on the date determined by the Access Health CT rules if we receive notice
from you instructing us to end your coverage.
Other Events Ending Your Coverage
When any of the following happen, we will provide written notice to the Policyholder that coverage has
ended on the date we identify in the notice:

Failure to Pay
You fail to pay the required Premium.

Fraud or Intentional Misrepresentation of a Material Fact
You committed an act, practice, or omission that constituted fraud, or an intentional
misrepresentation of a material fact. Examples include knowingly providing incorrect information
relating to another person's eligibility or status as a Dependent.
During the first two years the Policy is in effect, if we find that you have performed an act, practice,
or omission that constitutes fraud, or have made an intentional misrepresentation of material fact,
we have the right to demand that you pay back all Benefits we paid to you, or paid in your name,
during the time you were incorrectly covered under the Policy.

You Accept Reimbursement for Premium
You accept any direct or indirect contribution or reimbursement by or on behalf of any third party
including, but not limited to, any health care provider or any health care provider sponsored
organization for any portion of the Premium for coverage under this Policy. This prohibition does
not apply to the following third parties:

Ryan White HIV/AIDS Program under title XXVI of the Public Health Service Act.

Indian tribes, tribal organizations or urban Indian organizations

State and Federal Government programs.
Coverage for a Disabled Dependent Child
Coverage for an unmarried Enrolled Dependent child who is disabled will not end just because the child
has reached a certain age. We will extend the coverage for that child beyond the limiting age if both of the
following are true regarding the Enrolled Dependent child:

Is not able to be self-supporting because of mental or physical handicap or disability.

Depends mainly on the Policyholder for support.
Coverage will continue as long as the Enrolled Dependent is medically certified as disabled and
dependent unless coverage is otherwise terminated in accordance with the terms of this Policy.
We will ask you to furnish us with proof of the medical certification of disability within 31 days of the date
coverage would otherwise have ended because the child reached a certain age. Before we agree to this
extension of coverage for the child, we may require that a Physician chosen by us examine the child. We
will pay for that examination.
We may continue to ask you for proof that the child continues to be disabled and dependent. Such proof
might include medical examinations at our expense. However, we will not ask for this information more
than once a year.
If you do not provide proof of the child's disability and dependency within 31 days of our request as
described above, coverage for that child will end.
IEXPOL.I.15.CT
45
Reinstatement
When coverage under this Policy terminates for any reason, we will not reinstate coverage. You must
make application for coverage under another Policy, subject to the rules of the Access Health CT.
IEXPOL.I.15.CT
46
Section 5: How to File a Claim
If You Receive Covered Health Services from a Network Provider
We pay Network providers directly for your Covered Health Services. If a Network provider bills you for
any Covered Health Service, contact us. However, you are responsible for meeting any applicable
deductible and for paying any required Copayments and Coinsurance to a Network provider at the time of
service, or when you receive a bill from the provider.
If You Receive Covered Health Services from a Non-Network Provider
When you receive Covered Health Services from a non-Network provider, you are responsible for
requesting payment from us. You must file the claim in a format that contains all of the information we
require, as described below.
Notice of Claim
You should submit a request for payment of Benefits within 90 days after the date of service. If you don't
provide this information to us within one year of the date of service, Benefits for that health service will be
denied or reduced, as we determine. This time limit does not apply if you are legally incapacitated. If your
claim relates to an Inpatient Stay, the date of service is the date your Inpatient Stay ends.
If a provider of ambulance services complies with the statutory provision for direct payment and that
provider has not been paid from any other source, Eligible Expenses due to that provider will be paid
directly to that provider instead of being paid to you.
Claim Forms and Proof of Loss
We do not require that you complete and submit a claim form. Instead, you can provide proof of loss by
furnishing us with all of the information listed directly below under Required Information.
Required Information
When you request payment of Benefits from us, you must provide us with all of the following information:

The Policyholder's name and address.

The patient's name and age.

The number stated on your ID card.

The name and address of the provider of the service(s).

The name and address of any ordering Physician.

A diagnosis from the Physician.

An itemized bill from your provider that includes the Current Procedural Terminology (CPT) codes
or a description of each charge.

The date the Injury or Sickness began.

A statement indicating either that you are, or you are not, enrolled for coverage under any other
health insurance plan or program. If you are enrolled for other coverage you must include the name
of the other carrier(s).
The above information should be filed with us at the address on your ID card. When filing a claim for
Outpatient Prescription Drug Benefits, your claims should be submitted to:
Optum Rx
PO Box 29077
IEXPOL.I.15.CT
47
Hot Spring, AR 71903
Payment of Claims
Time for Payment of Claim
Benefits will be paid as soon as we receive all of the required information listed above.
Assignment of Benefits
When you receive Covered Health Services from a non-Network provider, we may reimburse you directly,
less any applicable Annual Deductible, Copayment and any amount that exceeds Eligible Expenses and
you will then be responsible for reimbursing the non-Network provider. The reimbursement will be based
on the definition of Eligible Expenses as described under Section 8: Defined Terms. You may assign your
right to reimbursement under this Certificate to a dentist or oral surgeon provided (1) the dentist or oral
surgeon does not charge you more than what the dentist/oral surgeon would charge an uninsured patient
for the same services, and (2) the dentist or oral surgeon allows Us to review medical records, with at
least 48 hours' notice, during regular business hours. For all other types of providers, you may not assign
your right to reimbursement under this Certificate to a non-Network provider without our consent. We
may, however, in our discretion, pay a non-Network provider directly for services rendered to you.
IEXPOL.I.15.CT
48
Section 6: Questions, Complaints and Appeals
To resolve a question, complaint, or appeal, just follow these steps:
What to Do if You Have a Question
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.
What to Do if You Have a Complaint
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.
If the Customer Care representative cannot resolve the issue to your satisfaction over the phone, he/she
can help you prepare and submit a written complaint. We will notify you of our decision regarding your
complaint within 60 days of receiving it.
How to Appeal a Claim Decision
This section describes the process for appealing a (1) utilization review (UR) decision or (2) a benefit,
network or administrative decision. The process you will need to use depends upon the type of issue you
are trying to resolve. Please read the information in the Section carefully, as it describes what the
different review procedures are and when and how to use them. If you are still not sure of the process to
follow, contact Customer Care at the telephone number shown on your ID card.
Copies of these procedures are available in many languages and can be forwarded to you subject to
availability. We can also arrange to have an independent interpreter available, however our ability to
provide this service depends on the availability of the interpreter. We may need to arrange to call you at a
time when an interpreter is available. Additionally, you always have the right to designate a representative
during this process.
Authorized Representatives
You have the right to use these procedures. It is your responsibility to initiate a Complaint or Appeal
within the timeframes set forth in this Policy.
You may designate a person to act on your behalf, including your healthcare provider ("authorized
representative"). For appeals of benefit determinations concerning urgent care, we are required to allow
your healthcare provider, with knowledge of your condition, to act as your authorized representative
without your written consent. A benefit determination concerning urgent care is defined as a
determination which, if subject to the standard appeal time frames, could seriously jeopardize your life or
health or your ability to regain maximum function, or in the opinion of a physician with knowledge of your
condition, would subject you to severe pain that cannot be adequately managed without care or treatment
that is the subject of the determination.
For all other circumstances, to authorize a representative to act on your behalf, you must provide us with
written consent at the time your complaint or appeal is submitted. Because your medical records are
privileged and confidential, and we want to ensure that you wish to appeal, you must submit an original
signed written consent. Enrolled Dependents who are 18 years of age or older will need to provide their
own signed written consent. If the Dependent is a minor, a written consent must be signed by the Enrolled
Dependent's parent or guardian.
IEXPOL.I.15.CT
49
Your authorized representative will only be authorized to act on your behalf and is required to comply with
all of the conditions of your Policy that would apply to you when you initiate any appeal or complaint. Your
authorized representative is not entitled to obtain any benefits or rights under your Policy.
Utilization Review (UR) Appeals
UR will occur whenever judgments pertaining to medical necessity and the provision of services or
treatments are rendered. The utilization review appeals process should be used after you have received
an initial adverse UR determination and you do not agree with our decision. All appeals are subject to a
review by us to evaluate the medical necessity of the services. You may use this process to appeal
adverse determinations relating to all UR determinations, regardless of whether the services requested by
you or your authorized representative have not yet been rendered (pre-service), are currently being
rendered (concurrent) or have already been rendered (post-service).
Please note: This UR appeals process should not be used for appeals relating to benefit, network or
administrative issues.
UR appeals must be initiated within 180 days from receipt of an adverse determination (i.e., receipt of the
determination notice). A decision may be rendered within the standard timeframes or may be expedited
as described in this section.
While a UR appeal may be filed by telephone or in writing, we strongly recommend that you file your
appeal in writing. The written request will give us a clear understanding of the issues being appealed. In
addition to your request for an appeal, you or your authorized representative must send any
documentation/information already requested by us (if not previously submitted) and any additional
written comments and documentation/information you would like to submit in support of the appeal. At the
time of our review, we will review all available comments, documentation and information.
Unless we have already issued a written determination, we will use our best efforts to provide written
acknowledgement of the receipt of your appeal within 5 business days, but in no event later than 15
calendar days. Our decision to either uphold or reverse the adverse determination will be made and
communicated to you as follows:

Request for service (pre-service): Within 30 calendar days of our receipt of the appeal.

Concurrent services for a member in an ongoing course of treatment (concurrent): Within 30
calendar days of our receipt of the appeal. In this instance, treatment will be continued without
liability while your appeal is being reviewed.

Coverage for services rendered (post-service): Within 60 calendar days of our receipt of the
appeal.
If we do not follow the process outlined in this section, you will have been deemed to have exhausted the
internal appeals process and may then file a request for an external review (see below), regardless of
whether we can assert substantial compliance or deminimis error.
This will be our final adverse determination. If you are not satisfied with our decision, you have the option
of filing an External Appeal (explained in the section below, "External Appeals."
Expedited/Urgent Utilization Review (UR) Appeals
You can expedite your UR appeal when:
IEXPOL.I.15.CT
50

You receive an adverse determination involving continued or extended health care services,
procedures or treatments or additional services while you are undergoing a course of continued
treatment (concurrent) prescribed by a health care provider; or

The timeframes of the non-expedited UR appeal process would seriously jeopardize your life,
health or ability to regain maximum function; or

In the opinion of a physician with knowledge of the health condition, the timeframes of the nonexpedited UR appeal process would cause you severe pain that cannot be managed without the
care of treatment that was requested; or

Your physician believes an immediate appeal is necessary because the timeframes of the nonexpedited UR appeal process would significantly increase the risk to your health; or

For a substance use disorder, a co-occurring mental disorder or a mental disorder requiring
inpatient services, partial hospitalization, residential treatment or intensive outpatient services
necessary to keep a covered person from requiring an inpatient setting.
You have two available options for expedited reviews. These options are not available for health care
services that have already been rendered (post-service).
1. Internal Expedited UR Appeal: This process includes procedures to facilitate a timely resolution of the
appeal including, but not limited to, the sharing of information between your provider and us by telephone
or facsimile. We will provide reasonable access to our clinical peer reviewer within one business day of
receiving notice of an expedited UR appeal.
A decision will be rendered and communicated for an internal expedited UR appeal within the following
timeframes:

24 hours from our receipt of the appeal when the service being appealed is for substance use
disorder or co-occurring mental disorder; and inpatient services, partial hospitalization, residential
treatment or those intensive outpatient services needed to keep the member from requiring an
inpatient setting in connection with a mental disorder.

72 hours from our receipt of the appeal for all other types of services.
If you are not satisfied with the outcome of the expedited UR appeal, you may further appeal through the
external appeal process. If we do not make a determination within 24/72 hours of receipt of the necessary
information, the adverse determination will be reversed.
The notice of an appeal determination will include the reasons for the determination. If the adverse
determination is upheld on appeal, the notice will include the specific reason(s) and clinical rationale used
to render the determination, a reference to the specific health benefit plan provisions on which the
decision is based, a statement that you may receive from us, upon request and free of charge,
reasonable access to and copies of all relevant documents. We will also include a notice of your right to
initiate an External Appeal. A description of each process and associated timeframes will be included.
If we do not follow the process outlined in this section, you will have been deemed to have exhausted the
internal appeals process and may then file a request for an external review (see below), regardless of
whether we can assert substantial compliance or deminimis error.
2. External Expedited Appeal: You also have the option to seek review by an independent review
organization in emergency or life-threatening circumstances. You may make a request to the
Commissioner of Insurance for an expedited external appeal without first completing the internal appeals
process if:
IEXPOL.I.15.CT
51

The timeframe for completion of an expedited internal appeal may cause or exacerbate an
emergency or life-threatening situation; or

For a substance use disorder, a co-occurring mental disorder or a mental disorder requiring
inpatient services, partial hospitalization, residential treatment or intensive outpatient services
necessary to keep a covered person from requiring an inpatient setting; and

You, or your provider acting on your behalf with your consent, have filed a request for expedited
internal review.
If you choose this option, you must submit the appeal by contacting the Connecticut Insurance
Department at P.O. Box 816, Hartford, CT 06142-0816 (telephone number: 860-297-3910). For more
information on how to file an expedited external appeal, refer to External UR Appeals below.
Office of the Healthcare Advocate and the Division of Consumer
Affairs
If we deny a requested service on the basis that the service is not medically necessary or because it is a
contractual exclusion and you believe you have been given erroneous information, you have the right to
contact either Connecticut's Office of the Healthcare Advocate or Division of Consumer Affairs for
assistance. You may contact them at the address listed below:
State of Connecticut
Office of the Healthcare Advocate
P.O. Box 1543
Hartford, CT 06114
Telephone: 1-866-466-4446
E-mail: [email protected]
Consumer Affairs Division
P.O. Box 816
Hartford, CT 06142-0816
Telephone: 1-800-203-3447
E-mail: [email protected]
External UR Appeals
Under certain circumstances, you or, with your consent, your authorized representative or provider acting
on your behalf, have a right to file an external appeal or expedited external appeal for the denial of
coverage for services based on lack of medically necessary criteria or because the service is
experimental or investigational for a particular medical condition. Benefit or administrative determinations
are not eligible for external appeal; only utilization review issues are eligible for external appeal.
You or your authorized representative have the right to request an external UR appeal in the following
situations:

The service, procedure or treatment must otherwise be a covered service under this Policy; and
IEXPOL.I.15.CT
52

You must have received a final adverse determination through the UR appeals review, with a
denial based on lack of medical necessity criteria or experimental/investigational treatment
UNLESS it is determined that the timeframe for completion of an internal appeal may cause or
exacerbate and emergency or life threatening situation. In an emergency or life-threatening
situation, you or your authorized provider acting on your behalf with your consent would not need to
complete the internal UR appeal in order to file for an external appeal.
All requests for external review or expedited external review must be accompanied by a $25.00 filing
fee. In the event the external appeal agent overturns the adverse determination, the fee will be refunded.
You will not be required to pay more than $75.00 in a calendar year for filing fees. The Connecticut
Insurance Commissioner will waive the filing fee if the fee will pose a hardship to you as determined by
the Commissioner.
How to File an External Appeal
To file an expedited external appeal, you can submit an application with the Connecticut Insurance
Department immediately following receipt of our initial adverse determination or appeal determination.
If the expedited external appeal is not accepted on an expedited basis, and you have not previously
completed the internal UR appeal process, you may resume the internal appeal process until all internal
appeals are exhausted. You may then file for a standard external appeal within 120 days following receipt
of the final denial letter.
If the internal appeals were previously exhausted, your rejected expedited appeal will automatically be
eligible for consideration for standard external appeal. You are not required to submit a new application.
Remember: You may not file an expedited external review for services which have already been
provided (post-service).
To file a non-expedited external appeal, you have 120 days to initiate the appeal through the State of
Connecticut Insurance Department after you have completed the internal UR appeal or after We and you
both agree to waive the internal appeal process
Requests for external appeals and expedited external appeals must be in writing on an external appeal
application form. The application form will include instructions on how to complete and submit the form to
the Commissioner. You or your authorized representative (and Provider, if applicable) must release all
pertinent medical information concerning your medical condition and request for services. You may
contact Connecticut’s Insurance Department at the following address or telephone number:
Connecticut Insurance Department
PO Box 816
Attn: Utilization Review Nurse Coordinator
(860) 297-3910
For Overnight delivery only, please send Your application for External Review to: State of Connecticut
Insurance Department
153 Market Street
P.O. Box 816
860-297-3910
The following items must be included in your Appeal. Your Appeal will be rejected if all of these items are
not included:
IEXPOL.I.15.CT
53

A completed "request for External Appeal" form.

An authorization form allowing us and your health care professional to release your medical
information to the independent review organization.

Evidence of being an enrollee of the plan (photocopy of your insurance card).

Copies of all correspondence from us.

A copy of the final determination letter indicating that all internal appeal mechanisms have been
exhausted.

A copy of your policy.

The filing fee of $25. Please make check or money order payable to: Treasurer-State of
Connecticut). In cases of financial hardship, this fee may be waived.
In addition to the required items outlined above, you may also submit any additional information relevant
to your condition.
Following receipt of the request for external appeal or expedited external appeal, the Insurance
Commissioner will forward the appeal to us so that we may confirm that your appeal is complete and
satisfies the conditions listed below. We will complete this review within 5 business days for an external
review request or within 1 day for an expedited external review request.
1. You are or were a Covered Person at the time of the event that is subject of the adverse
determination;
2. The service in question reasonably appears to be a covered service under the Policy but was denied
because it does not meet our requirements for medical necessity, appropriateness, health care
setting, level of care or effectiveness;
3. The service in question reasonably appears to be a covered Service under the Policy but was denied
because it is experimental or investigational for a particular medical condition, is not explicitly listed
as an excluded benefit under your health benefit plan and your treating health care professional
has certified that one of the following situations is applicable:

Standard health care services or treatments have not been effective in improving your
medical condition;

Standard health care services are not medically appropriate for you.

There is no available standard health care service or treatment covered by us that is more
beneficial than the recommended or requested health care service or treatment.
In addition, your treating health care professional:

Has recommended a health care service or treatment that he/she certifies, in writing, is likely
to be more beneficial to you, in his/her opinion, than any available standard health care
services or treatments; or

Is a licensed, board certified or board eligible health care professional qualified to practice in
the area of medicine appropriate to treat your condition and has certified in writing that
scientifically valid studies using accepted protocols demonstrate that the denied health care
service or treatment is likely to be more beneficial to you than any available standard health
care services or treatments.
4. You have completed at least the First Level Appeal process;
5. You have provided all of the required information; and
IEXPOL.I.15.CT
54
6. You have paid the required filing fee.
Once we have completed our review, we will notify you, your authorized representative (if appropriate)
and the Insurance Commissioner whether the appeal is complete and eligible for external review. We will
communicate our findings in writing within 1 business day for an external appeal or on the day the review
is completed for an expedited external appeal. If your appeal is not complete, the notice will include what
information or materials are missing. If your appeal is not eligible, the notice will include the reason(s) it is
not eligible. In either instance, you may appeal this determination to the Insurance Commissioner.
If your appeal is eligible for external review, the Commissioner will assign your appeal to an Independent
Review Organization. The Commissioner will send a notice to you and authorized representative (if
appropriate) informing you that 1) your external review or expedited external review has been accepted,
and 2) that you have 5 business days from receipt of the notice to submit any additional information.
We will forward the medical and treatment plan records we relied upon in making our determination to the
Independent Review Organization. If the documentation represents a material change from the
documentation upon which we based our adverse determination or denial, we will have the opportunity to
consider the documentation and amend or confirm our adverse determination or denial. This review will
not delay or terminate the external review.
The Independent Review Organization will make a determination with regard to the appeal within the
following timeframes:

External Reviews: within 45 days after assignment from the Commissioner

External Review involving an experimental or investigational treatment: within 20 days after
assignment from the Commissioner

Expedited External Reviews: as expeditiously as your condition requires, but not later than:


24 hours after assignment from the Commissioner when the service being appealed is for
substance use disorder or co-occurring mental disorder; and inpatient services, partial
hospitalization, residential treatment or those intensive outpatient services needed to keep
the member from requiring an inpatient setting in connection with a mental disorder.

72 hours after assignment from the Commissioner for all other types of services.
Expedited External Reviews involving an experimental or investigational treatment: as
expeditiously as your conditions requires, but not later than 5 days after assignment from the
Commissioner
Upon completion of the review, the Independent Review Organization will communicate it’s decision in
writing to you, your authorized representative (if appropriate), the Commissioner and to us. If the decision
is to reverse or revise our initial or final adverse determination, we will immediately approve the coverage,
subject to the terms and conditions of this Policy. The decision will be binding.
Benefit/Administrative Appeals
The benefit/administrative appeals process is used after you have received an initial adverse
determination concerning a claim for benefits or an administrative issue. Benefit issues include, but are
not limited to: denials based on benefit exclusions or limitations and claims payment disputes.
Administrative issues would include issues such as access to providers, eligibility or enrollment issues.
Please Note: Benefit and administrative issues do not include determinations concerning the medical
necessity of covered services. If we have denied your claims or request for services because we believe
IEXPOL.I.15.CT
55
the services are not medically necessary, do not use the process outlined in this section. Please refer to
the above section, Utilization Review (UR) Appeals.
While a UR appeal may be filed by telephone or in writing, we strongly recommend that you file your
appeal in writing. The written request will give us a clear understanding of the issues being appealed. In
addition to your request for an appeal, you or your authorized representative must send any
documentation/information already requested by us (if not previously submitted) and any additional
written comments and documentation/information you would like to submit in support of the appeal. At the
time of our review, we will review all available comments, documentation and information.
Within 3 business days of receipt of your appeal, we will send you a notice informing you of your right to
submit to us any additional written material you would like us to consider as part of our review. The notice
will also provide the address, telephone number and the name of the Department handling your appeal.
Benefit/administrative appeals must be initiated by you or your authorized representative within 180 days
from receipt of an adverse determination (i.e., an Explanation of Benefits, Denial Notice) or, for other
issues, from the date when you became aware of the issue that initiated the appeal.
We will provide you or your authorized representative or your provider with our written decision (by mail or
electronic means) and the detailed reasons for our decision including clinical rationale (if applicable) and
references to any specific plan provisions on which our decision was based within the following
timeframes:

Standard Appeal: Within 20 business days of receipt of your appeal.

Expedited Grievance (Urgent Care): Within 48 hours of receipt of all necessary information or 72
hours from receipt of the appeal, whichever is shorter.
This will be our final position.
How to Request an Appeal
If you disagree with either a pre-service request for Benefits determination, post-service claim
determination or a rescission of coverage determination, you can contact us in writing to formally request
an appeal.
Your request for an appeal should include:

The patient's name and the identification number from the ID card.

The date(s) of medical service(s).

The provider's name.

The reason you believe the claim should be paid.

Any documentation or other written information to support your request for claim payment.
Your first appeal request must be submitted to us within 180 days after you receive the denial of a preservice request for Benefits or the claim denial.
Appeal Process
A qualified individual who was not involved in the decision being appealed will be appointed to decide the
appeal. If your appeal is related to clinical matters, the review will be done in consultation with a health
care professional with appropriate expertise in the field, who was not involved in the prior determination.
We may consult with, or seek the participation of, medical experts as part of the appeal resolution
process. You consent to this referral and the sharing of pertinent medical claim information. Upon request
and free of charge, you have the right to reasonable access to and copies of all documents, records and
other information relevant to your claim for Benefits. In addition, if any new or additional evidence is relied
IEXPOL.I.15.CT
56
upon or generated by us during the determination of the appeal, we will provide it to you free of charge
and sufficiently in advance of the due date of the response to the adverse benefit determination.
Within 3 business days of receipt of your appeal, we will send you a notice informing you of your right to
submit to us any additional written material you would like us to consider as part of our review. The notice
will also provide the address, telephone number and the name of the Department handling your appeal.
IEXPOL.I.15.CT
57
Section 7: General Legal Provisions
Your Relationship with Us
In order to make choices about your health care coverage and treatment, we believe that it is important
for you to understand how we interact with your Policy and how it may affect you. We administer the
Policy under which you are insured. We do not provide medical services or make treatment decisions.
This means:

We communicate to you decisions about whether the Policy will cover or pay for the health care
that you may receive. The plan pays for Covered Health Services, which are more fully described
in this Policy.

The Policy may not pay for all treatments you or your Physician may believe are necessary. If the
Policy does not pay, you will be responsible for the cost.
We may use individually identifiable information about you to identify for you (and you alone) procedures,
products or services that you may find valuable. We will use individually identifiable information about you
as permitted or required by law, including in our operations and in our research. We will use de-identified
data for commercial purposes including research.
Please refer to our Notice of Privacy Practices for details.
Our Relationship with Providers
The relationships between us and Network providers are solely contractual relationships between
independent contractors. Network providers are not our agents or employees. Neither we nor any of our
employees are agents or employees of Network providers.
We do not provide health care services or supplies, nor do we practice medicine. Instead, we arrange for
health care providers to participate in a Network and we pay Benefits. Network providers are independent
practitioners who run their own offices and facilities. Our credentialing process confirms public information
about the providers' licenses and other credentials, but does not assure the quality of the services
provided. They are not our employees nor do we have any other relationship with Network providers such
as principal-agent or joint venture. We are not liable for any act or omission of any provider.
Your Relationship with Providers
The relationship between you and any provider is that of provider and patient.

You are responsible for choosing your own provider.

You are responsible for paying, directly to your provider, any amount identified as a member
responsibility, including Copayments, Coinsurance, any deductible and any amount that exceeds
Eligible Expenses.

You are responsible for paying, directly to your provider, the cost of any non-Covered Health
Service.

You must decide if any provider treating you is right for you. This includes Network providers you
choose and providers to whom you have been referred.

You must decide with your provider what care you should receive.

Your provider is solely responsible for the quality of the services provided to you.
Incentives to Providers
We pay Network providers through various types of contractual arrangements, some of which may
include financial incentives to promote the delivery of health care in a cost efficient and effective manner.
These financial incentives are not intended to affect your access to health care.
IEXPOL.I.15.CT
58
Examples of financial incentives for Network providers are:

Bonuses for performance based on factors that may include quality, member satisfaction and/or
cost-effectiveness.

Capitation - a group of Network providers receives a monthly payment from us for each Covered
Person who selects a Network provider within the group to perform or coordinate certain health
services. The Network providers receive this monthly payment regardless of whether the cost of
providing or arranging to provide the Covered Person's health care is less than or more than the
payment.
We use various payment methods to pay specific Network providers. From time to time, the payment
method may change. If you have questions about whether your Network provider's contract with us
includes any financial incentives, we encourage you to discuss those questions with your provider. You
may also contact us at the telephone number on your ID card. We can advise whether your Network
provider is paid by any financial incentive, including those listed above; however, the specific terms of the
contract, including rates of payment, are confidential and cannot be disclosed.
Incentives to You
Sometimes we may offer coupons or other incentives to encourage you to participate in various wellness
programs or certain disease management programs. The decision about whether or not to participate is
yours alone but we recommend that you discuss participating in such programs with your Physician.
These incentives are not Benefits and do not alter or affect your Benefits. Contact us if you have any
questions.
Rebates and Other Payments
We may receive rebates for certain drugs that are administered to you in your home or in a Physician's
office, or at a Hospital or Alternate Facility. This includes rebates for those drugs that are administered to
you before you meet any applicable deductible. We do not pass these rebates on to you, nor are they
applied to any deductible or taken into account in determining your Copayments or Coinsurance.
Interpretation of Benefits
We have the sole and exclusive authority to do all of the following:

Interpret Benefits under this Policy.

Interpret the other terms, conditions, limitations and exclusions set out in this Policy, including the
Schedule of Benefits and any Riders and/or Amendments.

Make factual determinations related to this Policy and its Benefits.
We may delegate this authority to other persons or entities that provide services in regard to the
administration of this Policy.
In certain circumstances, for purposes of overall cost savings or efficiency, we may, as we determine,
offer Benefits for services that would otherwise not be Covered Health Services. The fact that we do so in
any particular case shall not in any way be deemed to require us to do so in other similar cases.
This section is subject to the decisions rendered in Section 6: Questions, Complaints and Appeals, as you
always have the right to file a complaint or appeal.
Administrative Services
We may, as we determine, arrange for various persons or entities to provide administrative services in
regard to this Policy, such as claims processing. The identity of the service providers and the nature of
the services they provide may be changed from time to time, as we determine. We are not required to
give you prior notice of any such change, nor are we required to obtain your approval. You must
cooperate with those persons or entities in the performance of their responsibilities.
IEXPOL.I.15.CT
59
Amendments to this Policy
To the extent permitted by law, we reserve the right to change, interpret, modify, withdraw or add Benefits
or terminate this Policy.
Any provision of this Policy which, on its effective date, is in conflict with the requirements of state or
federal statutes or regulations (of the jurisdiction in which this Policy is delivered) is hereby amended to
conform to the minimum requirements of such statutes and regulations.
No other change may be made to this Policy unless it is made by an Amendment or Rider which has
been signed by one of our officers. All of the following conditions apply:

Amendments to this Policy are effective 31 days after we send written notice to the Policyholder.

Riders are effective on the date we specify.

No agent has the authority to change this Policy or to waive any of its provisions.

No one has authority to make any oral changes or amendments to this Policy.
Information and Records
We may use your individually identifiable health information to administer this Policy and pay claims, to
identify procedures, products, or services that you may find valuable, and as otherwise permitted or
required by law. We may request additional information from you to decide your claim for Benefits. We will
keep this information confidential. We may also use your de-identified data for commercial purposes,
including research, as permitted by law. More detail about how we may use or disclose your information is
found in our Notice of Privacy Practices.
By accepting Benefits under this Policy, you authorize and direct any person or institution that has
provided services to you to furnish us with all information or copies of records relating to the services
provided to you. We have the right to request this information at any reasonable time. This applies to all
Covered Persons, including Enrolled Dependents whether or not they have signed the Policyholder's
enrollment form. We agree that such information and records will be considered confidential.
We have the right to release any and all records concerning health care services which are necessary to
implement and administer the terms of this Policy, for appropriate medical review or quality assessment,
or as we are required to do by law or regulation. During and after the term of this Policy, we and our
related entities may use and transfer the information gathered under this Policy in a de-identified format
for commercial purposes, including research and analytic purposes. Please refer to our Notice of Privacy
Practices.
For complete listings of your medical records or billing statements we recommend that you contact your
health care provider. Providers may charge you reasonable fees to cover their costs for providing records
or completing requested forms.
If you request medical forms or records from us, we also may charge you reasonable fees to cover costs
for completing the forms or providing the records.
In some cases, as permitted by law, we will designate other persons or entities to request records or
information from or related to you, and to release those records as necessary. Our designees have the
same rights to this information as we have.
Examination of Covered Persons
In the event of a question or dispute regarding your right to Benefits, we may require that a Network
Physician of our choice examine you at our expense.
Workers' Compensation not Affected
Benefits provided under this Policy do not substitute for and do not affect any requirements for coverage
by workers' compensation insurance.
IEXPOL.I.15.CT
60
Subrogation and Reimbursement
Subrogation is the substitution of one person or entity in the place of another with reference to a lawful
claim, demand or right. Immediately upon paying or providing any Benefit, we shall be subrogated to and
shall succeed to all rights of recovery, to the extent permitted by law, under any legal theory of any type
for the reasonable value of any services and Benefits we provided to you, from any or all of the following
listed below.
In addition to any subrogation rights and in consideration of the coverage provided by this Policy, we shall
also have an independent right to be reimbursed by you for the reasonable value of any services and
Benefits we provide to you, from any or all of the following listed below.

Third parties, including any person alleged to have caused you to suffer injuries or damages.

Your employer.

Any person or entity who is or may be obligated to provide benefits or payments to you, including
benefits or payments for underinsured or uninsured motorist protection, no-fault or traditional auto
insurance, medical payment coverage (auto, homeowners or otherwise), workers' compensation
coverage, other insurance carriers or third party administrators.

Any person or entity who is liable for payment to you on any equitable or legal liability theory.
These third parties and persons or entities are collectively referred to as "Third Parties."
You agree as follows:

That you will cooperate with us in protecting our legal and equitable rights to subrogation and
reimbursement, including:

Providing any relevant information requested by us.

Signing and/or delivering such documents as we or our agents reasonably request to secure
the subrogation and reimbursement claim.

Responding to requests for information about any accident or injuries.

Making court appearances.

Obtaining our consent or our agents' consent before releasing any party from liability or
payment of medical expenses.

That failure to cooperate in this manner shall be deemed a breach of contract, and may result in
the termination of health benefits or the instigation of legal action against you.

That we have the authority to resolve all disputes regarding the interpretation of the language
stated herein.

That no court costs or attorneys' fees may be deducted from our recovery without our express
written consent; any so-called "Fund Doctrine" or "Common Fund Doctrine" or "Attorney's Fund
Doctrine" shall not defeat this right, and we are not required to participate in or pay court costs or
attorneys' fees to the attorney hired by you to pursue your damage/personal injury claim.

That regardless of whether you have been fully compensated or made whole, we may collect from
you the proceeds of any full or partial recovery that you or your legal representative obtain, whether
in the form of a settlement (either before or after any determination of liability) or judgment, with
such proceeds available for collection to include any and all amounts earmarked as non-economic
damage settlement or judgment.

That benefits paid by us may also be considered to be benefits advanced.

That you agree that if you receive any payment from any potentially responsible party as a result of
an injury or illness, whether by settlement (either before or after any determination of liability), or
judgment, you will serve as a constructive trustee over the funds, and failure to hold such funds in
trust will be deemed as a breach of your duties hereunder.
IEXPOL.I.15.CT
61

That you or an authorized agent, such as your attorney, must hold any funds due and owing us, as
stated herein, separately and alone, and failure to hold funds as such will be deemed as a breach
of contract, and may result in the termination of health benefits or the instigation of legal action
against you.

That we may set off from any future benefits otherwise provided by us the value of benefits paid or
advanced under this section to the extent not recovered by us.

That you will not accept any settlement that does not fully compensate or reimburse us without our
written approval, nor will you do anything to prejudice our rights under this provision.

That you will assign to us all rights of recovery against Third Parties, to the extent of the reasonable
value of services and Benefits we provided, plus reasonable costs of collection.

That our rights will be considered as the first priority claim against Third Parties, including
tortfeasors from whom you are seeking recovery, to be paid before any other of your claims are
paid.

That we may, at our option, take necessary and appropriate action to preserve our rights under
these subrogation provisions, including filing suit in your name, which does not obligate us in any
way to pay you part of any recovery we might obtain.

That we shall not be obligated in any way to pursue this right independently or on your behalf.

That in the case of your wrongful death, the provisions of this section will apply to your estate, the
personal representative of your estate and your heirs or beneficiaries.

That the provisions of this section apply to the parents, guardian, or other representative of a
Dependent child who incurs a Sickness or Injury caused by a Third Party. If a parent or guardian
may bring a claim for damages arising out of a minor's Injury, the terms of this subrogation and
reimbursement clause shall apply to that claim.
Refund of Overpayments
If we pay Benefits for expenses incurred on account of a Covered Person, that Covered Person, or any
other person or organization that was paid, must make a refund to us if any of the following apply:

All or some of the expenses were not paid by the Covered Person or did not legally have to be paid
by the Covered Person.

All or some of the payment we made exceeded the Benefits under this Policy.

All or some of the payment was made in error.
The refund equals the amount we paid in excess of the amount we should have paid under this Policy. If
the refund is due from another person or organization, the Covered Person agrees to help us get the
refund when requested.
If the Covered Person, or any other person or organization that was paid, does not promptly refund the
full amount, we may reduce the amount of any future Benefits for the Covered Person that are payable
under this Policy. The reductions will equal the amount of the required refund. We may have other rights
in addition to the right to reduce future benefits.
Limitation of Action
You cannot bring any legal action against us to recover reimbursement until you have completed all the
steps in the appeal process described in Section 6: Questions, Complaints and Appeals. After completing
that process, if you want to bring a legal action against us you must do so within three years of the date
we notified you of our final decision on your appeal or you lose any rights to bring such an action against
us.
IEXPOL.I.15.CT
62
Entire Policy
This Policy, including the Schedule of Benefits, the Policyholder's application and any Riders and/or
Amendments, constitutes the entire Policy.
IEXPOL.I.15.CT
63
Section 8: Defined Terms
Alternate Facility - a health care facility that is not a Hospital and that provides one or more of the
following services on an outpatient basis, as permitted by law:

Surgical services.

Emergency Health Services.

Rehabilitative, laboratory, diagnostic or therapeutic services.

Isolation care and emergency services provided by Connecticut's mobile field hospital.
An Alternate Facility may also provide Mental Health Services or Substance-Related and Addictive
Disorders Services on an outpatient or inpatient basis.
Amendment - any attached written description of additional or alternative provisions to this Policy.
Amendments are effective only when signed by us. Amendments are subject to all conditions, limitations
and exclusions of this Policy, except for those that are specifically amended.
Annual Deductible - this is the amount of Eligible Expenses you must pay for Covered Health Services
per year before we will begin paying for Benefits. The amount that is applied to the Annual Deductible is
calculated on the basis of Eligible Expenses. The Annual Deductible does not include any amount that
exceeds Eligible Expenses. There may be differences in the Annual Deductible depending on whether
your plan only covers you or it also covers family members. Refer to the Schedule of Benefits for details
about how the Annual Deductible applies.
Applied Behavior Analysis - the design, implementation and evaluation of environmental modifications,
using behavioral stimuli and consequences, including the use of direct observation, measurement and
functional analysis of the relationship between environment and behavior, to produce socially significant
improvement in human behavior.
Autism Spectrum Disorders - the pervasive developmental disorders set forth in the most recent edition
of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, including
but not limited to Autistic Disorder, Rhett's Syndrome, Asperger's Disorder, Childhood Disintegrated
Disorder and Pervasive Development Disorders Not Otherwise Specified (PDDNOS).
Behavior Therapy - any interactive behavioral therapies derived from evidence-based research,
including, but not limited to, applied behavior analysis, cognitive behavioral therapy, or other therapies
supported by empirical evidence of the effective treatment of individuals diagnosed with an Autism
Spectrum Disorder, that are:

Provided to children less than fifteen years of age; and

Provided or supervised by any of the following:

a behavior analyst who is certified by the Behavior Analyst Certification Board,

a licensed Physician, or

a licensed psychologist.
Behavioral Therapy is considered to be supervised by a behavior analyst, licensed Physician or licensed
psychologist when the supervision entails at least one hour of face-to-face supervision of the autism
services provided for each ten hours of behavioral therapy provided by the supervised provider.Benefits your right to payment for Covered Health Services that are available under this Policy. Your right to
Benefits is subject to the terms, conditions, limitations and exclusions of this Policy, including the
Schedule of Benefits and any attached Riders and/or Amendments.
Clinical Peer - will be used for reviews of adverse determinations and external review determinations. A
clinical peer is a physician or other health care professional who:
IEXPOL.I.15.CT
64

(A) holds a non-restricted license in a state of the United States and in the same or similar specialty
as typically manages the medical condition, procedure or treatment under review, and

(B) for an urgent care review concerning

A child or adolescent substance use disorder or a child or adolescent mental disorder, holds
(1) a national board certification in child and adolescent psychiatry, or (2) a doctoral level
psychology degree with training and clinical experience in the treatment of child and
adolescent substance use disorder or child and adolescent mental disorder, as applicable, or

An adult substance use disorder or an adult mental disorder, holds (1) a national board
certification in psychiatry, or (2) a doctoral level psychology degree with training and clinical
experience in the treatment of adult substance use disorders or adult mental disorders, as
applicable.
Coinsurance - the charge, stated as a percentage of Eligible Expenses, that you are required to pay for
certain Covered Health Services.
Congenital Anomaly - a physical developmental defect that is present at the time of birth, and that is
identified within the first twelve months of birth.
Copayment - the charge, stated as a set dollar amount, that you are required to pay for certain Covered
Health Services.
Please note that for Covered Health Services, you are responsible for paying the lesser of the following:

The applicable Copayment.

The Eligible Expense.
Cosmetic Procedures - procedures or services that change or improve appearance without significantly
improving physiological function, as determined by us.
Covered Health Service(s) - those health services, including services, supplies, or Pharmaceutical
Products, which we determine to be all of the following:


Described as a Covered Health Service in this Policy under Section 1: Covered Health Services
and in the Schedule of Benefits.

Covered Person - either the Policyholder or an Enrolled Dependent, but this term applies only while the
person is enrolled under this Policy. References to "you" and "your" throughout this Policy are references
to a Covered Person.
Custodial Care - services that are any of the following:

Non-health-related services, such as assistance in activities of daily living (examples include
feeding, dressing, bathing, transferring and ambulating).

Health-related services that are provided for the primary purpose of meeting the personal needs of
the patient or maintaining a level of function (even if the specific services are considered to be
skilled services), as opposed to improving that function to an extent that might allow for a more
independent existence.

Services that do not require continued administration by trained medical personnel in order to be
delivered safely and effectively.
Dependent - the Policyholder's legal spouse or a child of the Policyholder or the Policyholder's spouse.
The term child includes any of the following:

A natural child.

A stepchild.
IEXPOL.I.15.CT
65

A legally adopted child.

A child placed for adoption.

A child for whom legal guardianship has been awarded to the Policyholder or the Policyholder's
spouse.
The definition of Dependent is subject to the following conditions and limitations:

A Dependent includes any child listed above under 26 years of age.

A Dependent includes a dependent child age 26 or older who is or becomes disabled and
dependent upon the Policyholder.
The Policyholder must reimburse us for any Benefits that we pay for a child at a time when the child did
not satisfy these conditions.
A newly born child will be covered under the Policy from the moment of birth. This coverage includes
coverage for injury and sickness including necessary care and treatment of medically diagnosed
congenital defects and birth abnormalities within the limits of this Policy. You must notify and enroll the
baby within the first 61 days after birth for continued coverage.
Coverage will also be provided for a child who has legally been placed for adoption with the subscriber
who is an adoptive parent or a prospective adoptive parent, even though the adoption has not yet been
finalized, provided the child lives in the subscriber's household and the child is dependent upon the
subscriber for support and maintenance. This coverage includes coverage for injury and sickness
including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities
within the limits of this Policy. We must be notified, and applicable premium received, within 31 days after
the acceptance of the child in order to continue coverage beyond the 31 day period.
Coverage for a dependent child will end no earlier than the policy anniversary date on or after whichever
of the following occurs first: the date the child becomes covered under a group health plan through the
dependent's own employment or turns 26.
Designated Dispensing Entity - a pharmacy or other provider that has entered into an agreement with
us, or with an organization contracting on our behalf, to provide Pharmaceutical Products for the
treatment of specified diseases or conditions. The fact that a pharmacy or other provider is a Network
provider does not mean that it is a Designated Dispensing Entity.
Designated Facility - a facility that has entered into an agreement with us, or with an organization
contracting on our behalf, to render Covered Health Services for the treatment of specified diseases or
conditions. A Designated Facility may or may not be located within the Service Area. The fact that a
Hospital is a Network Hospital does not mean that it is a Designated Facility.
Designated Network Benefits - this is the description of how Benefits are paid for Covered Health
Services provided by a Physician or other provider that we have identified as Designated Network
providers. Refer to the Schedule of Benefits for details about how Designated Network Benefits apply.
Designated Physician - a Physician that we've identified through our designation programs as a
Designated provider. A Designated Physician may or may not be located within the Service Area. The
fact that a Physician is a Network Physician does not mean that he or she is a Designated Physician.
Durable Medical Equipment - medical equipment that is all of the following:

Can withstand repeated use.

Is not disposable.

Is used to serve a medical purpose with respect to treatment of a Sickness, Injury or their
symptoms.

Is generally not useful to a person in the absence of a Sickness, Injury or their symptoms.

Is appropriate for use, and is primarily used, within the home.
IEXPOL.I.15.CT
66

Is not implantable within the body.
Eligible Expenses - for Covered Health Services, incurred while this Policy is in effect, Eligible Expenses
are determined by us as stated below and as detailed in the Schedule of Benefits.
Eligible Expenses are determined solely in accordance with our reimbursement policy guidelines. We
develop our reimbursement policy guidelines, as we determine, following evaluation and validation of all
provider billings in accordance with one or more of the following methodologies:

As indicated in the most recent edition of the Current Procedural Terminology (CPT), a publication
of the American Medical Association, and/or the Centers for Medicare and Medicaid Services
(CMS).

As reported by generally recognized professionals or publications.

As used for Medicare.

As determined by medical staff and outside medical consultants pursuant to other appropriate
source or determination that we accept.
Insert Access Health for On-Exchange Plans. Insert Us for Off-Exchange Plans.
Eligible Person - a person who meets the eligibility requirements determined by the Access Health. An
Eligible Person must live within the Service Area.
Emergency - a serious medical condition or symptom resulting from Injury, Sickness or Mental Illness
which is both of the following:

Arises suddenly.

In the judgment of a reasonable person, requires immediate care and treatment, generally received
within 24 hours of onset, to avoid jeopardy to life or health.
Emergency Health Services - health care services and supplies necessary for the treatment of an
Emergency.
Enrolled Dependent - a Dependent who is properly enrolled under this Policy.
Experimental or Investigational Service(s) - medical, surgical, diagnostic, psychiatric, mental health,
substance-related and addictive 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
Pharmacopoeia Dispensing Information as appropriate for the proposed use, except that coverage
is provided for a drug which has been prescribed for treatment of certain types of cancer for which
the drug has not been approved by the FDA, provided the drug is recognized for the treatment of
the specific type of cancer for which the drug has been prescribed in one of the following three
established reference compendia: (1) The U.S. Pharmacopoeia Drug Information Guide for the
Health Care Professional (USPDI); (2) The American Medical Association's Drug Evaluations
(AMADE); or (3) The American Society of Hospital's Pharmacist's American Hospital Formulary
Service Drug Information (AHES-DI). However, there is no coverage for any drug which the FDA
has determined to be contraindicated for the specific cancer for which the drug has been
prescribed.

Subject to review and approval by any institutional 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 I, II or III clinical trial set
forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight,
except that Benefits for a procedure, treatment or the use of any drug will not be denied as
IEXPOL.I.15.CT
67
experimental if such procedure, treatment or drug, for the illness of condition being treated, or for
the diagnosis for which it is being prescribed, has successfully completed a Phase 3 clinical trial.
Exceptions:

Clinical trials for which Benefits are available as described under Clinical Trials in Section 1:

If you are not a participant in a qualifying clinical trial, as described under Clinical Trials in Section
1: Covered Health Services, and have a Sickness or condition that is likely to cause death within
one year of the request for treatment we may, as we determine, consider an otherwise
Experimental or Investigational 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.
Freestanding Facility - A freestanding facility is an outpatient, diagnostic or ambulatory center or
independent laboratory which performs services and submits claims as a freestanding entity, not as a
hospital. A freestanding facility is determined through the "Billed Place of Service Code" the provider
includes in their claim. For example, if a provider rendered a service and submitted it with a "Billed Place
of Service Code" of 22 (outpatient hospital), we consider that a hospital-based facility. If a claim is
submitted with a "Billed Place of Service Code" of 24, we consider that a freestanding facility.
Genetic Testing - examination of blood or other tissue for chromosomal and DNA abnormalities and
alterations, or other expressions of gene abnormalities that may indicate an increased risk for developing
a specific disease or disorder.
Home Health Agency - an agency or organization which meets all of the following:

Is primarily engaged in and is federally certified as a home health agency and is duly licensed (if
such licensing is required) by the appropriate licensing authority to provide nursing and other
therapeutic services.

Has their policy established by a professional group associated with the agency or organization,
including at least one Physician and at least one registered nurse, to govern the services provided.

Provides for full-time supervision of such services by a Physician or by a registered nurse.

Maintains a complete medical record on each patient.

Has an administrator.
Hospital - an institution that is operated as required by law and that meets both of the following:

It is primarily engaged in providing health services, on an inpatient basis, for the acute care and
treatment of injured or sick individuals. Care is provided through medical, diagnostic and surgical
facilities, by or under the supervision of a staff of Physicians.

It has 24-hour nursing services.
A Hospital is not primarily a place for rest, Custodial Care or care of the aged and is not a nursing home,
convalescent home or similar institution. A Hospital is not a skilled nursing facility or an inpatient
rehabilitation facility.
Individual Treatment Plan - a treatment plan prescribed by a Physician with specific attainable goals
and objectives appropriate to both the patient and the treatment modality of the program.
Injury - bodily damage other than Sickness, including all related conditions and recurrent symptoms.
Inpatient Rehabilitation Facility - a long term acute rehabilitation center, a Hospital (or a special unit of
a Hospital designated as an Inpatient Rehabilitation Facility) that provides rehabilitation health services
(including physical therapy, occupational therapy and/or speech therapy) on an inpatient basis, as
authorized by law.
IEXPOL.I.15.CT
68
Inpatient Stay - an uninterrupted confinement that follows formal admission to a Hospital, Skilled Nursing
Facility or Inpatient Rehabilitation Facility.
Intensive Outpatient Treatment - a structured outpatient mental health or substance-related and
addictive disorders treatment program that may be free-standing or Hospital-based and provides services
for at least three hours per day, two or more days per week.
Intermittent Care - skilled nursing care that is provided or needed either:

Fewer than seven days each week.

Fewer than eight hours each day for periods of 21 days or less.
Exceptions may be made in exceptional circumstances when the need for additional care is finite and
predictable.
Medically Necessary - health care services provided for the purpose of preventing, evaluating,
diagnosing or treating a Sickness, Injury, Mental Illness, substance-related and addictive disorders,
condition, disease or its symptoms, that are all of the following as determined by us or our designee.

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-related and addictive disorders,
disease or its symptoms.

Not mainly for your convenience or that of your doctor or other health care provider.

Not more costly than an alternative 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.
If no credible scientific evidence is available, then standards that 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. In determining
whether health care services are Medically Necessary, we reserve the right to consult a subject matter
expert of our choice and apply physician relevant specialty society recommendations.
We develop and maintain clinical policies that describe the Generally Accepted Standards of Medical
Practice scientific evidence, prevailing medical standards and clinical guidelines supporting our
determinations regarding specific services. These clinical policies (as developed by us and revised from
time to time), are available to Covered Persons on www.myuhc.com or by calling Customer Care at the
telephone number on your ID card, and to Physicians and other health care professionals on
UnitedHealthcareOnline.
Medicare - Parts A, B, C and D of the insurance program established by Title XVIII, United States Social
Security Act, as amended by 42 U.S.C. Sections 1394, et seq. and as later amended.
Mental Health Services - Covered Health Services for the diagnosis and treatment of Mental Illnesses.
The fact that a condition is listed in the current Diagnostic and Statistical Manual of the American
Psychiatric Association does not mean that treatment for the condition is a Covered Health Service.
Mental Health/Substance-Related and Addictive Disorders Designee - the organization or individual,
designated by us, that provides or arranges Mental Health Services and Substance-Related and
Addictive Disorders Services for which Benefits are available under this Policy.
IEXPOL.I.15.CT
69
Mental Illness - those mental health or psychiatric diagnostic categories that are listed in the current
Diagnostic and Statistical Manual of the American Psychiatric Association, unless those services are
specifically excluded under this Policy.
Network - when used to describe a provider of health care services, this means a provider that has a
participation agreement in effect (either directly or indirectly) with us or with our affiliate to participate in
our Network; however, this does not include those providers who have agreed to discount their charges
for Covered Health Services. Our affiliates are those entities affiliated with us through common ownership
or control with us or with our ultimate corporate parent, including direct and indirect subsidiaries.
A provider may enter into an agreement to provide only certain Covered Health Services, but not all
Covered Health Services, or to be a Network provider for only some of our products. In this case, the
provider will be a Network provider for the Covered Health Services and products included in the
participation agreement, and a non-Network provider for other Covered Health Services and products.
The participation status of providers will change from time to time.
Network Benefits - this is the description of how Benefits are paid for Covered Health Services provided
by Network providers. Refer to the Schedule of Benefits for details about how Network Benefits apply.
Non-Network Benefits - this is the description of how Benefits are paid for Covered Health Services
provided by non-Network providers. Refer to the Schedule of Benefits for details about how Non-Network
Benefits apply.
Out-of-Pocket Maximum - the maximum amount of Eligible Expenses you pay every year for Covered
Health Services. Refer to the Schedule of Benefits for details about how the Out-of-Pocket Maximum
applies.
Partial Hospitalization/Day Treatment - a structured ambulatory program that may be a free-standing or
Hospital-based program and that provides services for at least 20 hours per week.
Pharmaceutical Product(s) - U.S. Food and Drug Administration (FDA)-approved prescription
pharmaceutical products administered in connection with a Covered Health Service by a Physician or
other health care provider within the scope of the provider's license, and not otherwise excluded under
this Policy.
Physician - any Doctor of Medicine or Doctor of Osteopathy who is properly licensed and qualified by
law.
Please Note: Any alcohol and drug counselor, marital and family therapist, naturopath, nurse midwife,
nurse practitioner, social worker, podiatrist, dentist, psychologist, chiropractor, optometrist, or other
provider who acts within the scope of his or her license will be considered on the same basis as a
Physician. The fact that we describe a provider as a Physician does not mean that Benefits for services
from that provider are available to you under this Policy.
Policy - the entire agreement that includes all of the following:

This Policy.

The Schedule of Benefits.

The Policyholder's application.

Riders.

Amendments.
These documents make up the entire agreement that is issued to the Policyholder.
Policyholder - the person (who is not a Dependent) to whom this Policy is issued.
Pregnancy - includes all of the following:

Prenatal care.

Postnatal care.
IEXPOL.I.15.CT
70

Childbirth.

Any complications associated with Pregnancy.
Premium - the periodic fee required for each Policyholder and each Enrolled Dependent, in accordance
with the terms of this Policy.
Primary Physician - a Physician who has a majority of his or her practice in general pediatrics, internal
medicine, family practice or general medicine.
Private Duty Nursing - nursing care that is provided to a patient on a one-to-one basis by licensed
nurses in an inpatient or home setting when any of the following are true:

No skilled services are identified.

Skilled nursing resources are available in the facility.

The skilled care can be provided by a Home Health Agency on a per visit basis for a specific
purpose.

The service is provided to a Covered Person by an independent nurse who is hired directly by the
Covered Person or his/her family. This includes nursing services provided on an inpatient or homecare basis, whether the service is skilled or non-skilled independent nursing.
Qualified Health Plan Issuer - a health insurance issuer that offers a Qualified Health Plan in
accordance with a certification from Access Health.
Residential Treatment Facility - a facility which provides a program of effective Mental Health Services
or Substance-Related and Addictive Disorders Services treatment and which meets all of the following
requirements:

It is established and operated in accordance with applicable state law for residential treatment
programs.

It provides a program of treatment under the active participation and direction of a Physician and
approved by the Mental Health/Substance-Related and Addictive Disorders Designee.

It has or maintains a written, specific and detailed treatment program requiring full-time residence
and full-time participation by the patient.

It provides at least the following basic services in a 24-hour per day, structured milieu:

Room and board.

Evaluation and diagnosis.

Counseling.

Referral and orientation to specialized community resources.
A Residential Treatment Facility that qualifies as a Hospital is considered a Hospital.
Rider - any attached written description of additional Covered Health Services not described in this
Policy. Covered Health Services provided by a Rider may be subject to payment of additional Premiums.
Riders are effective only when signed by us and are subject to all conditions, limitations and exclusions of
this Policy except for those that are specifically amended in the Rider.
Routine Patient Care Costs - Expenses that are incurred as a result of either of the following:

Services provided to a Covered Person for purposes of a cancer clinical trial or a clinical trial for a
disabling or life-threatening chronic disease that would otherwise be Covered Health Services if
such services were not rendered pursuant to a cancer clinical trial or a clinical trial for a disabling or
life-threatening chronic disease. This includes services rendered by a Physician, diagnostic or
laboratory tests, hospitalization or other services provided to the Covered Person during the course
of treatment in the cancer/disabling life-threatening chronic disease clinical trial for a condition, or
IEXPOL.I.15.CT
71
one of its complications, that is consistent with the usual and customary standard of care and
would be considered Covered Health Services if the Covered Person were not enrolled in a cancer
clinical trial or a clinical trial for a disabling or life-threatening chronic disease.

Drugs provided to the Covered Person as described in the defined term Experimental or
Investigational Services, provided such drugs have been approved for sale by the federal Food and
Drug Administration.
Routine Patient Care Costs do not include any of the following:

The cost of an investigational new drug or device that has not been approved for market for any
indication by the federal Food and Drug Administration.

The cost of a non-health care service that a Covered Person may be required to receive as a result
of the treatment being provided for the purpose of the cancer clinical trial or a clinical trial for a
disabling or life-threatening chronic disease.

Facility, ancillary, professional services and drug costs that are paid for by grants or funding for the
cancer clinical trial or a clinical trial for a disabling or life-threatening chronic disease.

Costs that would not otherwise be considered Covered Health Services including, but not limited to,
items which are excluded under Section 2: Exclusions and Limitations.

Transportation, lodging, food or any other expenses associated with travel to or from a facility
providing the cancer clinical trial or a clinical trial for a disabling or life-threatening chronic disease,
for the Covered Person or any family member or companion.
Semi-private Room - a room with two or more beds. When an Inpatient Stay in a Semi-private Room is a
Covered Health Service, the difference in cost between a Semi-private Room and a private room is a
Benefit only when a private room is necessary in terms of generally accepted medical practice, or when a
Semi-private Room is not available.
Service Area - the geographic area where we act as a Qualified Health Plan Issuer as approved by the
appropriate regulatory agency. Contact us to determine the exact geographic area we serve. The Service
Area may change from time to time.
Sickness - physical illness, disease or Pregnancy. The term Sickness as used in this Policy includes
Mental Illness and substance-related and addictive disorders, regardless of the cause or origin of the
Mental Illness or substance-related and addictive disorders.
Skilled Nursing Facility - a Hospital or nursing facility that is licensed and operated as required by law.
Specialist Physician - a Physician who has a majority of his or her practice in areas other than general
pediatrics, internal medicine, family practice or general medicine.
Substance-Related and Addictive Disorders Services - Covered Health Services for the diagnosis and
treatment of alcoholism and substance-related and addictive disorders that are listed in the current
Diagnostic and Statistical Manual of the American Psychiatric Association, unless those services are
specifically excluded. The fact that a disorder is listed in the Diagnostic and Statistical Manual of the
American Psychiatric Association does not mean that treatment of the disorder is a Covered Health
Service.
Transitional Care - Mental Health Services and Substance-Related and Addictive Disorders Services
that are provided through transitional living facilities, group homes and supervised apartments that
provide 24-hour supervision that are either:

Sober living arrangements such as drug-free housing or alcohol/drug halfway houses. These are
transitional, supervised living arrangements that provide stable and safe housing, an alcohol/drugfree environment and support for recovery. A sober living arrangement may be utilized as an
adjunct to ambulatory treatment when treatment doesn't offer the intensity and structure needed to
assist the Covered Person with recovery.
IEXPOL.I.15.CT
72

Supervised living arrangements which are residences such as transitional living facilities, group
homes and supervised apartments that provide members with stable and safe housing and the
opportunity to learn how to manage their activities of daily living. Supervised living arrangements
may be utilized as an adjunct to treatment when treatment doesn't offer the intensity and structure
needed to assist the Covered Person with recovery.
Unproven Service(s) - services, including medications, that are determined not to be effective for
treatment of the medical condition and/or not to have a beneficial effect on health outcomes due to
insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or cohort
studies in the prevailing published peer-reviewed medical literature.

Well-conducted randomized controlled trials. (Two or more treatments are compared to each other,
and the patient is not allowed to choose which treatment is received.)

Well-conducted cohort studies from more than one institution. (Patients who receive study
treatment are compared to a group of patients who receive standard therapy. The comparison
group must be nearly identical to the study treatment group.)
We have a process by which we compile and review clinical evidence with respect to certain health
services. From time to time, we issue medical and drug policies that describe the clinical evidence
available with respect to specific health care services. These medical and drug policies are subject to
change without prior notice. You can view these policies at www.myuhc.com.
Please note:

If you have a life-threatening Sickness or condition (one that is likely to cause death within one year
of the request for treatment) we may, as we determine, 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 Center - a facility that provides Covered Health Services that are required to prevent
serious deterioration of your health, and that are required as a result of an unforeseen Sickness, Injury, or
the onset of acute or severe symptoms.
IEXPOL.I.15.CT
73
Section 9: Outpatient Prescription Drug Coverage
Coverage Policies and Guidelines
Our Prescription Drug List (PDL) Management Committee is authorized to make tier placement changes
on our behalf. The PDL Management Committee makes the final classification of an FDA-approved
Prescription Drug Product to a certain tier by considering a number of factors including, but not limited to,
clinical and economic factors. Clinical factors may include, but are not limited to, evaluations of the place
in therapy, relative safety or relative efficacy of the Prescription Drug Product, as well as whether certain
supply limits or prior authorization requirements should apply. Economic factors may include, but are not
limited to, the Prescription Drug Product's acquisition cost including, but not limited to, available rebates
and assessments on the cost effectiveness of the Prescription Drug Product.
Some Prescription Drug Products are more cost effective for specific indications as compared to others;
therefore, a Prescription Drug Product may be listed on multiple tiers according to the indication for which
the Prescription Drug Product was prescribed, or according to whether it was prescribed by a Specialist
Physician.
We may periodically change the placement of a Prescription Drug Product among the tiers. These
changes generally will occur quarterly, but no more than six times per calendar year. These changes may
occur without prior notice to you.
When considering a Prescription Drug Product for tier placement, the PDL Management Committee
reviews clinical and economic factors regarding Covered Persons as a general population. Whether a
particular Prescription Drug Product is appropriate for an individual Covered Person is a determination
that is made by the Covered Person and the prescribing Physician.
NOTE: The tier status of a Prescription Drug Product may change periodically based on the process
described above. As a result of such changes, you may be required to pay more or less for that
Prescription Drug Product. Please access www.myuhc.com through the Internet or call Customer Care at
the telephone number on your ID card for the most up-to-date tier status.
Requesting Clinically Appropriate Drugs That Are Not Covered
We have developed a process for evaluating Benefits for a Prescription Drug Product that is not covered
under the plan. An expedited review is available based on exigent circumstances. Exigent circumstances
exist when you are suffering from a health condition that may seriously jeopardize your life, health or
ability to regain maximum function or when you are undergoing a current course of treatment using a noncovered drug. We will make our coverage determination on an expedited review based on exigent
circumstances and notify you or your designee and the prescribing physician of our coverage
determination no later than 24 hours after we receive the request. Contact the number on the back of
your ID card to begin this process.
Identification Card (ID Card) - Network Pharmacy
You must either show your ID card at the time you obtain your Prescription Drug Product at a Network
Pharmacy or you must provide the Network Pharmacy with identifying information that can be verified by
us during regular business hours.
If you don't show your ID card or provide verifiable information at a Network Pharmacy, you will be
required to pay the Usual and Customary Charge for the Prescription Drug Product at the pharmacy.
You may seek reimbursement from us as described in Section 5: How to File a Claim. When you submit a
claim on this basis, you may pay more because you failed to verify your eligibility when the Prescription
Drug Product was dispensed. The amount you are reimbursed will be based on the Prescription Drug
Charge, less the required Copayment or Coinsurance, Ancillary Charge, and any deductible that applies.
Submit your claim to:
IEXPOL.I.15.CT
74
Optum Rx
PO Box 29077
Hot Spring, AR 71903
Limitation on Selection of Pharmacies
If we determine that you may be using Prescription Drug Products in a harmful or abusive manner, or with
harmful frequency, your selection of Network Pharmacies may be limited. If this happens, we may require
you to select a single Network Pharmacy that will provide and coordinate all future pharmacy services.
Benefits will be paid only if you use the designated single Network Pharmacy. If you don't make a
selection within 31 days of the date we notify you, we will select a single Network Pharmacy for you.
Rebates and Other Payments
We may receive rebates for certain drugs included on the Prescription Drug List, including those drugs
that you purchase prior to meeting the Annual Drug Deductible. We do not pass these rebates on to you,
nor are they applied to the Annual Drug Deductible or Annual Deductible, or any combined medical and
pharmacy Annual Deductible stated in the Schedule of Benefits attached to your Policy or taken into
account in determining your Copayments or Coinsurance.
We, and a number of our affiliated entities, conduct business with various pharmaceutical manufacturers
separate and apart from this Section. Such business may include, but is not limited to, data collection,
consulting, educational grants and research. Amounts received from pharmaceutical manufacturers
pursuant to such arrangements are not related to this Section. We are not required to pass on to you, and
do not pass on to you, such amounts.
Coupons, Incentives and Other Communications
At various times, we may send mailings to you or to your Physician that communicate a variety of
messages, including information about Prescription Drug Products. These mailings may contain coupons
or offers from pharmaceutical manufacturers that enable you, at your discretion, to purchase the
described drug product at a discount or to obtain it at no charge. Pharmaceutical manufacturers may pay
for and/or provide the content for these mailings. Only your Physician can determine whether a change in
your Prescription Order or Refill is appropriate for your medical condition.
Maintenance Medication Program
If you require certain Maintenance Medications, we may direct you to the Mail Order Network Pharmacy
to obtain those Maintenance Medications. If you choose not to obtain your Maintenance Medications from
the Mail Order Network Pharmacy, you may opt-out of the Maintenance Medication Program each year
through the Internet at www.myuhc.com or by calling Customer Care at the telephone number on your ID
card.
Benefits for Prescription Drug Products
Benefits are available for Prescription Drug Products at either a Network Pharmacy or a non-Network
Pharmacy and are subject to Copayments or Coinsurance or other payments that vary depending on
which of the tiers of the Prescription Drug List the Prescription Drug Product is listed. Refer to the
Schedule of Benefits for applicable Copayments or Coinsurance requirements.
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.
Benefits are available for refills of Prescription Drug Products only when dispensed as ordered by a duly
licensed health care provider and only after 3/4 of the original Prescription Drug Product has been used.
Prescription Drugs from a Retail Network Pharmacy
Benefits are provided for Prescription Drug Products dispensed by a retail Network Pharmacy.
IEXPOL.I.15.CT
75
Refer to the Schedule of Benefits for details on retail Network Pharmacy supply limits.
Prescription Drugs from a Retail Non-Network Pharmacy
Benefits are provided for Prescription Drug Products dispensed by a retail non-Network Pharmacy.
If the Prescription Drug Product is dispensed by a retail non-Network Pharmacy, you must pay for the
Prescription Drug Product at the time it is dispensed and then file a claim for reimbursement with us, as
described in Section 5: How to File a Claim. We will not reimburse you for the difference between the
Predominant Reimbursement Rate and the non-Network Pharmacy's Usual and Customary Charge for
that Prescription Drug Product. We will not reimburse you for any non-covered drug product.
In most cases, you will pay more if you obtain Prescription Drug Products from a non-Network Pharmacy.
Refer to the Schedule of Benefits for details on retail non-Network Pharmacy supply limits.
IEXPOL.I.15.CT
76
Exclusions
Exclusions from coverage listed in the Policy apply also to this Section. In addition, the exclusions listed
below apply.
When an exclusion applies to only certain Prescription Drug Products, you can access www.myuhc.com
through the Internet or call Customer Care at the telephone number on your ID card for information on
which Prescription Drug Products are excluded.
1.
Coverage for Prescription Drug Products for the amount dispensed (days' supply or quantity limit)
2.
Coverage for Prescription Drug Products for the amount dispensed (days' supply or quantity limit)
which is less than the minimum supply limit.
3.
Prescription Drug Products dispensed outside the United States, except as required for Emergency
treatment.
4.
Drugs which are prescribed, dispensed or intended for use during an Inpatient Stay.
5.
Experimental or Investigational or Unproven Services and medications; medications used for
experimental indications and/or dosage regimens determined by us to be experimental,
investigational or unproven. This exclusion does not apply to drugs for the treatment of cancer that
have not been approved by the Federal Food and Drug Administration for that indication, if the drug
has been prescribed for a Covered Person who has been diagnosed with cancer, provided the drug
is recognized for treatment of the specific type of cancer for which the drug has been prescribed in
one of the following established reference compendia: (1) The U.S. Pharmacopeia Drug
Information Guide for the Health Care Professional (USPDI); (2) The American Medical
Association's Drug Evaluations (AMADE)l; or (3) The American Society of Hospital Pharmacists'
American Hospital Formulary Service Drug Information (AHFS-DI). This exception does not provide
coverage for any experimental or investigational drugs or any drug which the Federal Food and
Drug Administration has determined to be contraindicated for treatment of the specific type of
cancer for which the drug has been prescribed.
6.
Prescription Drug Products furnished by the local, state or federal government. Any Prescription
Drug Product to the extent payment or benefits are provided or available from the local, state or
federal government (for example, Medicare) whether or not payment or benefits are received,
except as otherwise provided by law.
7.
Subject to applicable law, prescription Drug Products for any condition, Injury, Sickness or Mental
Illness arising out of, or in the course of, employment for which benefits are available under any
workers' compensation law or other similar laws, whether or not a claim for such benefits is made
or payment or benefits are received.
8.
Any product dispensed for the purpose of appetite suppression or weight loss.
9.
A Pharmaceutical Product for which Benefits are provided in your Policy. This exclusion does not
apply to Depo Provera and other FDA approved drugs used for contraception.
10.
Durable Medical Equipment. Prescribed and non-prescribed outpatient supplies, other than the
diabetic supplies and inhaler spacers specifically stated as covered.
11.
General vitamins, except the following which require a Prescription Order or Refill: prenatal
vitamins, vitamins with fluoride, and single entity vitamins.
12.
Unit dose packaging or repackagers of Prescription Drug Products.
13.
Medications used for cosmetic purposes.
14.
Prescription Drug Products, including New Prescription Drug Products or new dosage forms, that
we determine do not meet the definition of a Covered Health Service.
IEXPOL.I.15.CT
77
15.
Prescription Drug Products as a replacement for a previously dispensed Prescription Drug Product
that was lost, stolen, broken or destroyed.
16.
Prescription Drug Products when prescribed to treat infertility except for those services and drugs
that are a covered benefit as outlined in Section 1: Covered Health Services.
18.
Drugs available over-the-counter that do not require a Prescription Order or Refill by federal or
state law before being dispensed, unless we have designated the over-the-counter medication as
eligible for coverage as if it were a Prescription Drug Product and it is obtained with a Prescription
Order or Refill from a Physician. Any Prescription Drug Product that is Therapeutically Equivalent
to an over-the-counter drug except when medically necessary.
19.
Certain New Prescription Drug Products and/or new dosage forms until the date they are reviewed
and assigned to a tier by our PDL Management Committee. except that such review and approval
of new Prescription Drug Products and/or new dosage forms will not be required for any drug
prescribed to treat a covered indication so long as the drug has been approved by the United
States Food and Drug Administration for at least one indication and the drug is recognized for
treatment of the covered indication in one of the standard reference compendia or in a substantially
accepted peer-reviewed medical literature. The standard reference compendia are noted above
under the Experimental, Investigational or Unproven Services Exclusion.
20.
Growth hormone for children with familial short stature (short stature based upon heredity and not
caused by a diagnosed medical condition).
21.
Any medication that is used for the treatment of erectile dysfunction or sexual dysfunction.
22.
Any product for which the primary use is a source of nutrition, nutritional supplements, or dietary
management of disease, even when used for the treatment of Sickness or Injury.
23.
A Prescription Drug Product that contains (an) active ingredient(s) available in and Therapeutically
Equivalent to another covered Prescription Drug Product unless medically necessary. Such
determinations may be made up to six times during a calendar year, and we may decide at any
time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this
provision.
24.
A Prescription Drug Product that contains (an) active ingredient(s) which is (are) a modified version
of and Therapeutically Equivalent to another covered Prescription Drug Product unless medically
necessary. Such determinations may be made up to six times during a calendar year, and we may
decide at any time to reinstate Benefits for a Prescription Drug Product that was previously
excluded under this provision.
25.
Certain Prescription Drug Products that have not been prescribed by a Specialist Physician.
26.
A Prescription Drug Product that contains marijuana, including medical marijuana.
27.
Certain Prescription Drug Products that exceed the minimum number of drugs required to be
covered under PPACA essential health benefit requirements in the applicable United States
Pharmacopeia category and class or applicable state benchmark plan category and class.
28.
Any product for which the primary use is a source of nutrition, nutritional supplements, or dietary
management of disease, even when used for the treatment of Sickness or Injury except for the
following products when administered under the direction of a Physician: 1) amino acid modified
preparations and low protein medical food products for the treatment of inherited metabolic
diseases, as defined by state law; and 2) Specialized Formulas when such Specialized Formulas
are medically necessary for the treatment of a disease or condition.
Defined Terms
Ancillary Charge - a charge, in addition to the Copayment and/or Coinsurance, that you are required to
pay when a covered Prescription Drug Product is dispensed at your or the provider's request, when a
IEXPOL.I.15.CT
78
Chemically Equivalent Prescription Drug Product is available on a lower tier. For Prescription Drug
Products from Network Pharmacies, the Ancillary Charge is calculated as the difference between the
Prescription Drug Charge or Maximum Allowable Cost (MAC) List price for Network Pharmacies for the
Prescription Drug Product on the higher tier, and the Prescription Drug Charge or Maximum Allowable
Cost (MAC) List price of the Chemically Equivalent Prescription Drug Product available on the lower tier.
For Prescription Drug Products from non-Network Pharmacies, the Ancillary Charge is calculated as the
difference between the Predominant Reimbursement Rate or Maximum Allowable Cost (MAC) List price
for non-Network Pharmacies for the Prescription Drug Product on the higher tier, and the Predominant
Reimbursement Rate or Maximum Allowable Cost (MAC) List price of the Chemically Equivalent
Prescription Drug Product available on the lower tier.
Annual Drug Deductible - the amount you are required to pay for Tier 4. Prescription Drug Products in a
year before we begin paying for Prescription Drug Products. Refer to the Outpatient Prescription Drug
Schedule of Benefits for details about how the Annual Drug Deductible applies.
Brand-name - a Prescription Drug Product: (1) which is manufactured and marketed under a trademark
or name by a specific drug manufacturer; or (2) that we identify as a Brand-name product, based on
available data resources including, but not limited to, First DataBank, that classify drugs as either brand
or generic based on a number of factors. You should know that all products identified as a "brand name"
by the manufacturer, pharmacy, or your Physician may not be classified as Brand-name by us.
Chemically Equivalent - when Prescription Drug Products contain the same active ingredient.
Generic - a Prescription Drug Product: (1) that is Chemically Equivalent to a Brand-name drug; or (2) that
we identify as a Generic product based on available data resources including, but not limited to, First
DataBank, that classify drugs as either brand or generic based on a number of factors. You should know
that all products identified as a "generic" by the manufacturer, pharmacy or your Physician may not be
classified as a Generic by us.
Maximum Allowable Cost (MAC) List - a list of Generic Prescription Drug Products that will be covered
at a price level that we establish. This list is subject to our periodic review and modification.
Network Pharmacy - a pharmacy that has:

Entered into an agreement with us or an organization contracting on our behalf to provide
Prescription Drug Products to Covered Persons.

Agreed to accept specified reimbursement rates for dispensing Prescription Drug Products.

Been designated by us as a Network Pharmacy.
New Prescription Drug Product - a Prescription Drug Product or new dosage form of a previously
approved Prescription Drug Product, for the period of time starting on the date the Prescription Drug
Product or new dosage form is approved by the U.S. Food and Drug Administration (FDA) and ending on
the earlier of the following dates:

The date it is assigned to a tier by our PDL Management Committee.

December 31st of the following calendar year.
Predominant Reimbursement Rate - the amount we will pay to reimburse you for a Prescription Drug
Product that is dispensed at a non-Network Pharmacy. The Predominant Reimbursement Rate for a
particular Prescription Drug Product dispensed at a non-Network Pharmacy includes a dispensing fee
and any applicable sales tax. We calculate the Predominant Reimbursement Rate using our Prescription
Drug Charge that applies for that particular Prescription Drug Product at most Network Pharmacies.
Prescription Drug Charge - the rate we have agreed to pay our Network Pharmacies, including the
applicable dispensing fee and any applicable sales tax, for a Prescription Drug Product dispensed at a
Network Pharmacy.
Prescription Drug List - a list that categorizes into tiers medications, products or devices that have been
approved by the U.S. Food and Drug Administration (FDA). This list is subject to our periodic review and
modification (generally quarterly, but no more than six times per calendar year). You may determine to
IEXPOL.I.15.CT
79
which tier a particular Prescription Drug Product has been assigned through the Internet at
Prescription Drug List (PDL) Management Committee - the committee that we designate for, among
other responsibilities, classifying Prescription Drug Products into specific tiers.
Prescription Drug Product - a medication, product or device that has been approved by the U.S. Food
and Drug Administration (FDA) and that can, under federal or state law, be dispensed only pursuant to a
Prescription Order or Refill. A Prescription Drug Product includes a medication that, due to its
characteristics, is appropriate for self-administration or administration by a non-skilled caregiver. For the
purpose of Benefits under the Policy, this definition includes:

Inhalers (with spacers).

Insulin.

The following diabetic supplies:


standard insulin syringes with needles;

blood-testing strips - glucose;

urine-testing strips - glucose;

ketone-testing strips and tablets;

lancets and lancet devices

insulin pump supplies, including infusion sets, reservoirs, glass cartridges, and insertion
sets;; and

glucose monitors.
Hypodermic needles or syringes.

Prescription Order or Refill- the directive to dispense a Prescription Drug Product issued by a duly
licensed health care provider whose scope of practice permits issuing such a directive.
Preventive Care Medications – the medications that are obtained at a Network Pharmacy with a
Prescription Order or Refill from a Physician and that are payable at 100% of the cost (without application
of any Copayment, Coinsurance, Annual Deductible or Annual Drug Deductible) as required by applicable
law under any of the following:

Evidence-based items or services that have in effect a rating of "A" or "B" in the current
recommendations of the United States Preventive Services Task Force.

With respect to infants, children and adolescents, evidence-informed preventive care and
screenings provided for in the comprehensive guidelines supported by the Health Resources and
Services Administration.

With respect to women, such additional preventive care and screenings as provided for in
comprehensive guidelines supported by the Health Resources and Services Administration.
You may determine whether a drug is a Preventive Care Medication through the internet at
Specialized Formula - A nutritional formula for children up to age twelve that is exempt from the general
requirements for nutritional labeling under the statutory and regulatory guidelines of the federal Food and
Drug Administration and is intended for use solely under medical supervision in the dietary management
of specific diseases.
Specialty Prescription Drug Product - Prescription Drug Products that are generally high cost, selfadministered biotechnology drugs used to treat patients with certain illnesses. Specialty Prescription Drug
Products inlcude certain drugs for Infertility. You may access a complete list of Specialty Prescription
IEXPOL.I.15.CT
80
Drug Products through the Internet at www.myuhc.com or by calling Customer Care at the telephone
number on your ID card.
Therapeutically Equivalent - when Prescription Drug Products have essentially the same efficacy and
adverse effect profile.
Usual and Customary Charge - the usual fee that a pharmacy charges individuals for a Prescription
Drug Product without reference to reimbursement to the pharmacy by third parties. The Usual and
Customary Charge includes a dispensing fee and any applicable sales tax.
IEXPOL.I.15.CT
81
Section 10: Pediatric Dental Services
Accessing Pediatric Dental Services
Network and Non-Network Benefits
Network Benefits - these Benefits apply when you choose to obtain Covered Dental Services from a
Network Dental Provider. You generally are required to pay less to the provider than you would pay for
services from a non-Network provider. Network Benefits are determined based on the contracted fee for
each Covered Dental Service. In no event, will you be required to pay a Network Dental Provider an
amount for a Covered Dental Service in excess of the contracted fee.
In order for Covered Dental Services to be paid as Network Benefits, you must obtain all Covered Dental
Services directly from or through a Network Dental Provider.
You must always verify the participation status of a provider prior to seeking services. From time to time,
the participation status of a provider may change. You can verify the participation status by calling us
and/or the provider. If necessary, we can provide assistance in referring you to Network Dental Provider.
We will make available to you a Directory of Network Dental Providers. You can also call Customer
Service to determine which providers participate in the Network. The telephone number for Customer
Service is on your ID card.
Non-Network Benefits - these Benefits apply when you decide to obtain Covered Dental Services from
non-Network Dental Providers. You generally are required to pay more to the provider than for Network
Benefits. Non-Network Benefits are determined based on our contracted fee(s) for Covered Dental
Services with a Network Dental Provider in the same geographic area for each Covered Dental Service.
The actual charge made by a non-Network Dental Provider for a Covered Dental Service may exceed the
contracted fee(s). As a result, you may be required to pay a non-Network Dental Provider an amount for a
Covered Dental Service in excess of the contracted fee(s). In addition, when you obtain Covered Dental
Services from non-Network Dental Providers, you must file a claim with us to be reimbursed for Eligible
Dental Expenses.
Covered Dental Services
You are eligible for Benefits for Covered Dental Services listed in this Section if such Dental Services are
Necessary and are provided by or under the direction of a Network Dental Provider.
Benefits are available only for Necessary Dental Services. The fact that a Dental Provider has performed
or prescribed a procedure or treatment, or the fact that it may be the only available treatment, for a dental
disease does not mean that the procedure or treatment is a Covered Dental Service under this Section.
Pre-Treatment Estimate
If the charge for a Dental Service is expected to exceed $500 or if a dental exam reveals the need for
fixed bridgework, you may notify us of such treatment before treatment begins and receive a pretreatment estimate. If you desire a pre-treatment estimate, you or your Dental Provider should send a
notice to us, via claim form, within 20 calendar days of the exam. If requested, the Dental Provider must
provide us with dental x-rays, study models or other information necessary to evaluate the treatment plan
for purposes of benefit determination.
We will determine if the proposed treatment is a Covered Dental Service and will estimate the amount of
payment. The estimate of Benefits payable will be sent to the Dental Provider and will be subject to all
terms, conditions and provisions of the Policy. Clinical situations that can be effectively treated by a less
costly, clinically acceptable alternative procedure will be assigned a benefit based on the less costly
procedure.
A pre-treatment estimate of Benefits is not an agreement to pay for expenses. This procedure lets you
know in advance approximately what portion of the expenses will be considered for payment.
IEXPOL.I.15.CT
82
Pre-Authorization
Pre-authorization is required for orthodontic services. Speak to your Dental Provider about obtaining a
pre-authorization before Dental Services are rendered. If you do not obtain a pre-authorization, Benefits
will be reduced by 50% of the scheduled Benefit or $500 per occurrence, whichever is less.
Benefits for Pediatric Dental Services
Benefits are provided for the Dental Services stated in this Section when such services are:
A.
Necessary.
B.
Provided by or under the direction of a Dental Provider.
C.
Clinical situations that can be effectively treated by a less costly, dental appropriate alternative
procedure will be assigned a Benefit based on the least costly procedure.
D.
Not excluded as described in Section 3: Pediatric Dental Services exclusions of this Section.
The following services will be covered under this plan:

Oral exams

Cleanings

X-Rays

Fluoride treatments

Sealants

Fillings

Oral Surgery

Partial and full dentures

Simple extractions

Root canals

Crowns

Braces
Network Benefits:
Benefits for Eligible Dental Expenses are determined as a percentage of the negotiated contract fee
between us and the provider rather than a percentage of the provider's billed charge. Our negotiated rate
with the provider is ordinarily lower than the provider's billed charge.
A Network provider cannot charge you or us for any service or supply that is not Necessary as
determined by us. If you agree to receive a service or supply that is not Necessary the Network provider
may charge you. However, these charges will not be considered Covered Dental Services and Benefits
will not be payable.
Non-Network Benefits:
Benefits for Eligible Dental Expenses from non-Network providers are determined as a percentage of our
contracted fee(s) for Covered Dental Services with a Network Dental Provider in the same geographic
area. You must pay the amount by which the non-Network provider's billed charge exceeds the Eligible
Dental Expense.
IEXPOL.I.15.CT
83
Annual Deductible
Benefits for pediatric Dental Services provided under this Section are subject to the Annual Deductible
stated in the Schedule of Benefits.
Pediatric Dental Exclusions
Except as may be specifically provided in this Section under Section 2: Benefits for Covered Dental
Services, Benefits are not provided under this Section for the following:
1.
Any Dental Service or Procedure not listed as a Covered Dental Service under Benefits for
Covered Dental Services.
2.
Dental Services that are not Necessary.
3.
Any Dental Procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are
those procedures that improve physical appearance.)
4.
Reconstructive surgery, regardless of whether or not the surgery is incidental to a dental disease,
Injury, or Congenital Anomaly, when the primary purpose is to improve physiological functioning of
the involved part of the body.
5.
Any Dental Procedure not directly associated with dental disease.
6.
Any Dental Procedure not performed in a dental setting.
7.
Procedures that are considered to be Experimental or Investigational or Unproven Services. This
includes pharmacological regimens not accepted by the American Dental Association (ADA)
Council on Dental Therapeutics. The fact that an Experimental, or Investigational or Unproven
Service, treatment, device or pharmacological regimen is the only available treatment for a
particular condition will not result in Benefits if the procedure is considered to be Experimental or
Investigational or Unproven in the treatment of that particular condition.
8.
Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized
in the dental office during the patient visit.
9.
Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal
hard tissue.
10.
Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except
excisional removal. Treatment of malignant neoplasms or Congenital Anomalies of hard or soft
tissue, including excision.
11.
Replacement of complete dentures, fixed and removable partial dentures or crowns and implants,
implant crowns and prosthesis if damage or breakage was directly related to provider error. This
type of replacement is the responsibility of the Dental Provider. If replacement is Necessary
because of patient non-compliance, the patient is liable for the cost of replacement.
12.
Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and
lower jaw bone surgery (including that related to the temporomandibular joint). Orthognathic
surgery, jaw alignment, and treatment for the temporomandibular joint.
13.
Charges for failure to keep a scheduled appointment without giving the dental office 24 hours
notice.
14.
Expenses for Dental Procedures begun prior to the Covered Person becoming enrolled for
coverage provided through this Section to the Policy.
15.
Dental Services otherwise covered under the Policy, but rendered after the date individual
coverage under the Policy terminates, including Dental Services for dental conditions arising prior
to the date individual coverage under the Policy terminates.
16.
Services rendered by a provider with the same legal residence as a Covered Person or who is a
member of a Covered Person’s family, including spouse, brother, sister, parent or child.
IEXPOL.I.15.CT
84
17.
Foreign Services are not covered unless required as an Emergency.
18.
Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or
reconstruction.
19.
Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion
(VDO).
20.
Billing for incision and drainage if the involved abscessed tooth is removed on the same date of
service.
21.
Placement of fixed partial dentures solely for the purpose of achieving periodontal stability.
22.
Acupuncture; acupressure and other forms of alternative treatment, whether or not used as
anesthesia.
23.
Orthodontic coverage does not include the installation of a space maintainer, any treatment related
to treatment of the temporomandibular joint, any surgical procedure to correct a malocclusion,
replacement of lost or broken retainers and/or habit appliances, and any fixed or removable
interceptiveorthodontic appliances previously submitted for payment under the plan.
24.
Placement of dental implants, implant-supported abutments and prostheses.
Claims for Pediatric Dental Services
When obtaining Dental Services from a non-Network provider, you will be required to pay all billed
charges directly to your Dental Provider. You may then seek reimbursement from us. Information about
claim timelines and responsibilities in Section 5: How to File a Claim apply to Covered Dental Services
provided under this Section, except that when you submit your claim, you must provide us with all of the
information identified below.
Reimbursement for Dental Services
You are responsible for sending a request for reimbursement to our office, on a form provided by or
satisfactory to us.
Claim Forms. It is not necessary to include a claim form with the proof of loss. However, the proof must
include all of the following information:

Covered Person's name and address.

Covered Person's identification number.

The name and address of the provider of the service(s).

A diagnosis from the Dental Provider including a complete dental chart showing extractions, fillings
or other dental services rendered before the charge was incurred for the claim.

Radiographs, lab or hospital reports.

Casts, molds or study models.

Itemized bill which includes the CPT or ADA codes or description of each charge.

The date the dental disease began.

A statement indicating that you are or you are not enrolled for coverage under any other health or
dental insurance plan or program. If you are enrolled for other coverage you must include the name
of the other carrier(s).
If you would like to use a claim form, call us at the telephone number stated on your ID Card and a claim
form will be sent to you. If you do not receive the claim form within 15 calendar days of your request, send
in the proof of loss with the information stated above.
IEXPOL.I.15.CT
85
Defined Terms for Pediatric Dental Services
The following definitions are in addition to those listed in Section 8: Defined Terms of the Policy:
Covered Dental Service – a Dental Service or Dental Procedure for which Benefits are provided under
this Section.
Dental Provider - any dentist or dental practitioner who is duly licensed and qualified under the law of
jurisdiction in which treatment is received to render Dental Services, perform dental surgery or administer
anesthetics for dental surgery.
Dental Service or Dental Procedures - dental care or treatment provided by a Dental Provider to a
Covered Person while the Policy is in effect, provided such care or treatment is recognized by us as a
generally accepted form of care or treatment according to prevailing standards of dental practice.
Eligible Dental Expenses - Eligible Dental Expenses for Covered Dental Services, incurred while the
Policy is in effect, are determined as stated below:

For Network Benefits, when Covered Dental Services are received from Network Dental Providers,
Eligible Dental Expenses are our contracted fee(s) for Covered Dental Services with that provider.

For Non-Network Benefits, when Covered Dental Services are received from Non-Network Dental
Providers, Eligible Dental Expenses are our contracted fee(s) for Covered Dental Services with a
Network Dental Provider in the same geographic area.
Necessary - Dental Services and supplies under this Section which are determined by us through caseby-case assessments of care based on accepted dental practices to be appropriate and are all of the
following:

Necessary to meet the basic dental needs of the Covered Person.

Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the
Dental Service.

Consistent in type, frequency and duration of treatment with scientifically based guidelines of
national clinical, research, or health care coverage organizations or governmental agencies that
are accepted by us.

Consistent with the diagnosis of the condition.

Required for reasons other than the convenience of the Covered Person or his or her Dental
Provider.

Demonstrated through prevailing peer-reviewed dental literature to be either:

Safe and effective for treating or diagnosing the condition or sickness for which their use is
proposed; or

Safe with promising efficacy
♦
For treating a life threatening dental disease or condition.
♦
Provided in a clinically controlled research setting.
♦
Using a specific research protocol that meets standards equivalent to those defined
by the National Institutes of Health.
(For the purpose of this definition, the term life threatening is used to describe dental diseases or
sicknesses or conditions, which are more likely than not to cause death within one year of the date of the
request for treatment.)
The fact that a Dental Provider has performed or prescribed a procedure or treatment or the fact that it
may be the only treatment for a particular dental disease does not mean that it is a Necessary Covered
Dental Service as defined in this Section. The definition of Necessary used in this Section relates only to
IEXPOL.I.15.CT
86
Benefits under this Section and differs from the way in which a Dental Provider engaged in the practice of
dentistry may define necessary.
IEXPOL.I.15.CT
87
Section 11: Pediatric Vision Services
Benefits for Pediatric Vision Care Services
Benefits are available for pediatric Vision Care Services from a Spectera Eyecare Networks or nonNetwork Vision Care Provider. To find a Spectera Eyecare Networks Vision Care Provider, you may call
the provider locator service at 1-800-839-3242. You may also access a listing of Spectera Eyecare
Networks Vision Care Providers on the Internet at www.myuhcvision.com.
When you obtain Vision Care Services from a non-Network Vision Care Provider, you will be required to
pay all billed charges at the time of service. You may then seek reimbursement from us as described in
Section 5: How to File a Claim and in this Section under Claims for Vision Care Services. Reimbursement
will be limited to the amounts stated below.
Network Benefits:
Benefits for Vision Care Services are determined based on the negotiated contract fee between us and
the Vision Care Provider. Our negotiated rate with the Vision Care Provider is ordinarily lower than the
Vision Care Provider's billed charge.
Non-Network Benefits:
Benefits for Vision Care Services from non-Network providers are determined as a percentage of the
provider's billed charge.
Annual Deductible
Benefits for pediatric Vision Care Services provided under this Section are subject to any Annual
Deductible stated in the Schedule of Benefits.
Routine Vision Examination
A routine vision examination of the condition of the eyes and principal vision functions according to the
standards of care in the jurisdiction in which you reside, including:

A case history that includes chief complaint and/or reason for examination, patient medical/eye
history, and current medications.

Recording of monocular and binocular visual acuity, far and near, with and without present
correction (for example, 20/20 and 20/40).

Cover test at 20 feet and 16 inches (checks eye alignment).

Ocular motility including versions (how well eyes track) near point convergence (how well eyes
move together for near vision tasks, such as reading), and depth perception.

Pupil responses (neurological integrity).

External exam.

Retinoscopy (when applicable) – objective refraction to determine lens power of corrective lenses
and subjective refraction to determine lens power of corrective lenses.

Phorometry/Binocular testing – far and near: how well eyes work as a team.

Tests of accommodation and/or near point refraction: how well you see at near point (for example,
reading).

Tonometry, when indicated: test pressure in eye (glaucoma check).

Ophthalmoscopic examination of the internal eye.

Confrontation visual fields.
IEXPOL.I.15.CT
88

Biomicroscopy.

Color vision testing.

Diagnosis/prognosis.

Specific recommendations.
Post examination procedures will be performed only when materials are required.
Or, in lieu of a complete exam, Retinoscopy (when applicable) - objective refraction to determine lens
power of corrective lenses and subjective refraction to determine lens power of corrective lenses.
Eyeglass Lenses
Lenses that are mounted in eyeglass frames and worn on the face to correct visual acuity limitations.
You are eligible to select only one of either eyeglasses (Eyeglass Lenses and/or Eyeglass Frames) or
Contact Lenses. If you select more than one of these Vision Care Services, we will pay Benefits for only
one Vision Care Service.
Lens Extras
Eyeglass Lenses. The following Lens Extras are covered in full:

Standard scratch-resistant coating.

Polycarbonate lenses.
Eyeglass Frames
A structure that contains eyeglass lenses, holding the lenses in front of the eyes and supported by the
bridge of the nose.
Contact Lenses
Lenses worn on the surface of the eye to correct visual acuity limitations.
Benefits include the fitting/evaluation fees and contacts.
Necessary Contact Lenses
Benefits are available when a Vision Care Provider has determined a need for and has prescribed the
contact lens. Such determination will be made by the Vision Care Provider and not by us.
Contact lenses are necessary if you have any of the following:

Keratoconus.

Anisometropia.

Irregular corneal/astigmatism.

Aphakia.

Facial deformity.

Corneal deformity.
IEXPOL.I.15.CT
89
Pediatric Vision Exclusions
Except as may be specifically provided in this Section under Section 1: Benefits for Pediatric Vision Care
Services, Benefits are not provided under this Section for the following:
1.
Medical or surgical treatment for eye disease which requires the services of a Physician and for
which Benefits are available as stated in the Policy.
2.
Non-prescription items (e.g. Plano lenses).
3.
Replacement or repair of lenses and/or frames that have been lost or broken.
4.
Optional Lens Extras not listed in Section 1: Benefits for Vision Care Services.
5.
Missed appointment charges.
6.
Applicable sales tax charged on Vision Care Services.
Claims for Pediatric Vision Care Services
When obtaining Vision Care Services from a non-Network Vision Care Provider, you will be required to
pay all billed charges directly to your Vision Care Provider. You may then seek reimbursement from us.
Information about claim timelines and responsibilities in the Policy in Section 5: How to File a Claim
applies to Vision Care Services provided under this Section, except that when you submit your claim, you
must provide us with all of the information identified below.
Reimbursement for Vision Care Services
To file a claim for reimbursement for Vision Care Services rendered by a non-Spectera Eyecare Networks
Vision Care Provider, or for Vision Care Services covered as reimbursements (whether or not rendered
by a Spectera Eyecare Networks Vision Care Provider or a non-Network Vision Care Provider), you must
provide all of the following information on a claim form acceptable to us:

Your itemized receipts.

Covered Person's name.

Covered Person's identification number from the ID card.

Covered Person's date of birth.
Submit the above information to us:
By mail:
Claims Department
P.O. Box 30978
Salt Lake City, UT 84130
By facsimile (fax):
248-733-6060
Defined Terms for Pediatric Vision Care Services
The following definitions are in addition to those listed in Section 8: Defined Terms of the Policy:
Covered Contact Lens Selection - a selection of available contact lenses that may be obtained from a
Spectera Eyecare Networks Vision Care Provider on a covered-in-full basis, subject to payment of any
applicable Copayment.
Spectera Eyecare Networks - any optometrist, ophthalmologist, optician or other person designated by
us who provides Vision Care Services for which Benefits are available under the Policy.
IEXPOL.I.15.CT
90
Vision Care Provider - any optometrist, ophthalmologist, optician or other person who may lawfully
provide Vision Care Services.
Vision Care Service - any service or item listed in this Section in Section 1: Benefits for Pediatric Vision
Care Services.
IEXPOL.I.15.CT
91
INDIVIDUAL MARKET
Gold Choice Plus POS
SCHEDULE OF BENEFITS
Deductible and Out-of-Pocket
Maximum
In-Network (INET)
Member Pays
Out-of-Network (OON) Member
Pays
Deductible – The individual deductible applies if you have coverage only for yourself and not for any Dependents. The
family deductible applies if you have coverage for yourself and one or more eligible Dependents. If you have family
coverage, each covered family member needs to satisfy his or her individual deductible, not the entire family deductible,
prior to receiving benefits that are subject to the deductible.
Plan Deductible
$1,500 per member
$3,000 per member
Individual
$3,000 per family
$6,000 per family
Family
Separate Prescription Drug Deductible
Individual
$100 per member
Same as In-Network
$3,000 per member
$6,000 per member
$6,000 per family
$12,000 per family
In-Network (INET)
Member Pays
Pays
Adult Preventive Visit
No Cost
50% coinsurance per visit after OON
deductible is met
Infant / Pediatric Preventive Visit
No Cost
deductible is met
Primary Care Provider Office Visits
$30 Copayment per visit
deductible is met
Specialist Office Visits
Mental Health and Substance Abuse
Office Visit
deductible is met
deductible is met
Out-of-Pocket Maximum
Individual
Family
(Includes deductible, copayments and
coinsurance)
Benefits
Provider Office Visits
(includes services for illness, injury, followup care and consultations)
Outpatient Diagnostic Services
Advanced Radiology (CT/PET Scan, MRI)
Copayments for MRIs and CAT scans are
limited to $375 from in-network
SBN.IEX.CHP.I.16.CT_CP_1500
Freestanding Facility: Covered at 100%
after INET deductible is met
deductible is met
Hospital-Based Facility: $75 Copayment
Page 1 of 14
HIOS ID: 49650CT0060008-01
INDIVIDUAL MARKET
Maximum
In-Network (INET)
Member Pays
Pays
providers annually. Copayments for PET
scans are limited to $400 from innetwork providers annually.
per visit after INET deductible is met
Please refer to your provider directory
to identify freestanding facilities and
hospital-based facilities.
$30 Copayment per visit after INET
deductible is met
deductible is met
Non-Advanced Radiology (X-ray,
Diagnostic)
deductible is met
deductible is met
Mammography Ultrasound
deductible is met
deductible is met
Tier 1
$5 Copayment per prescription
$5 Copayment per prescription
Tier 2
$40 Copayment per prescription after
INET prescription deductible is met
50% coinsurance up to $500 maximum
per prescription per prescription after
Laboratory Services
Prescription Drugs - Retail Pharmacy
up to 30 day supply per prescription
Tier 3
Prescription Drugs - Mail Order or Retail Pharmacy
(90 day supply per prescription)
Tier 1 Prescription Drugs
$12.50 Copayment per prescription
$12.50 Copayment per prescription
INET prescription drug deductible is met
INET prescription drug deductible is met
Outpatient Rehabilitative and Habilitative Services
Speech Therapy
deductible is met
deductible is met
(40 visits per calendar year limit combined
for physical, speech, and occupational
therapy)
Physical and Occupational Therapy
(40 visits per calendar year limit combined
for physical, speech, and occupational
therapy)
Page 2 of 14
HIOS ID: 49650CT0060008-01
INDIVIDUAL MARKET
Maximum
In-Network (INET)
Member Pays
Pays
deductible is met
When obtained from a pharmacy: If
50% coinsurance per equipment/supply
after OON deductible is met
Other Services
Chiropractic Services
(up to 20 visits per calendar year)
Diabetic Equipment and Supplies
you obtain Diabetic Equipment or
Supplies from an in-network pharmacy,
your cost share responsibility will be the
same cost share amount reflected under
the Prescription Drug section (based on
the tier the item is placed).
Durable Medical Equipment (DME)
Home Health Care Services
When obtained from any other type of
provider: $0 Copayment per
equipment/supply after INET deductible
is met
$0 Copayment per DME item after INET
deductible is met
No Cost
50% coinsurance per DME item after
OON deductible is met
25% coinsurance per visit
Freestanding Facility: $0 Copayment
per visit after INET deductible is met
deductible is met
(up to 100 visits per calendar year)
Outpatient Services
Hospital-Based Facility: $500
Copayment per visit after INET
deductible is met
Please refer to your provider directory
to identify freestanding facilities and
hospital-based facilities.
Inpatient Services
Inpatient Hospital Services (including
mental health, substance abuse,
maternity, hospice and skilled nursing
facility*)
$500 Copayment per day up to a
maximum of $2,000 per admission after
INET deductible is met
deductible is met
Emergency Room
$0 Copayment after INET deductible is
met
met
Urgent Care Centers
deductible is met
*
(skilled nursing facility stay is limited to 90
days per calendar year)
Emergency and Urgent Care
Ambulance Services
Page 3 of 14
HIOS ID: 49650CT0060008-01
INDIVIDUAL MARKET
Maximum
In-Network (INET)
Member Pays
Pays
Pediatric Dental Care (for children under age 19)
Diagnostic & Preventive
No Cost
Basic Services
met
met
met
Major Services
Orthodontia Services
(medically necessary only)
deductible is met
deductible is met
deductible is met
deductible is met
Pediatric Vision Care (for children under age 19)
Prescription Eye Glasses
(one pair of frames and lenses or contact
lens per calendar year)
Routine Eye Exam by Specialist
(one exam per calendar year)
Lenses: $0 Copayment after INET
deductible is met;
Frames: $0 Copayment after INET
deductible is met
deductible is met
met
deductible is met
I. ADDITIONAL INFORMATION: MEDICAL SERVICES
Emergency Health Services - Outpatient
If you are confined in a non-Network Hospital after you receive outpatient Emergency Health Services, you must notify us
within one business day or on the same day of admission if reasonably possible. We may elect to transfer you to a Network
Hospital as soon as it is medically appropriate to do so. If you choose to stay in the non-Network Hospital after the date we
decide a transfer is medically appropriate, Network Benefits will not be provided. Non-Network Benefits may be available if the
continued stay is determined to be a Covered Health Service.
Eligible Expenses for Emergency Health Services provided by a non-Network provider will be determined as described below
under Eligible Expenses in this Schedule of Benefits. As a result, you will be responsible for the difference between the
amount billed by the non-Network provider and the amount we determine to be an Eligible Expense for
reimbursement.
Benefit Limitations
The benefits listed below have the following limitations:
Hearing Aids:
Repair and replacement of hearing aids will be covered once every 24 months.
Page 4 of 14
HIOS ID: 49650CT0060008-01
INDIVIDUAL MARKET
Outpatient Rehabilitation and Habilitative Services:
Post-Cochlear Implant Aural Therapy is limited to 30 visits per calendar year
Cognitive Therapy is limited to 20 visits per calendar year
Vision Exam, Adult:
For members who are 19 years of age or older and who are diagnosed with diabetes, We will cover one vision exam per
calendar year. Vision exams for members who are younger than 19 years of age are covered under the Pediatric Vision
benefit.
Wigs:
Benefit is limited to 1 wig per year for members suffering hair loss as a result of chemotherapy or radiation
therapy.
Accessing Benefits
You can choose to receive Network Benefits or Non-Network Benefits.
Network Benefits apply to Covered Health Services that are provided by a Network Physician or other Network provider. You
are not required to select a Primary Physician in order to obtain Network Benefits. In general health care terminology, a
Primary Physician may also be referred to as a Primary Care Physician or PCP.
Emergency Health Services provided by a non-Network provider will be reimbursed as set forth under Eligible Expenses as
described below. As a result, you will be responsible for the difference between the amount billed by the non-Network
provider and the amount we determine to be an Eligible Expense for reimbursement. The payments you make to nonNetwork providers for charges above the Eligible Expense do not apply towards any applicable Out-of-Pocket
Maximum.
For facility charges, these are Benefits for Covered Health Services that are billed by a Network facility and provided under
the direction of either a Network or non-Network Physician or other provider. Benefits for non-Emergency Covered Health
Services include Physician services provided in a Network facility by a Network or a non-Network Emergency room Physician,
radiologist, anesthesiologist or pathologist.
Non-Network Benefits apply to Covered Health Services that are provided by a non-Network Physician or other non-Network
provider, or Covered Health Services that are provided at a non-Network facility.
You must show your identification card (ID card) every time you request health care services from a Network provider. If you
do not show your ID card, Network providers have no way of knowing that you are enrolled under a UnitedHealthcare Policy.
As a result, they may bill you for the entire cost of the services you receive.
Additional information about the network of providers and how your Benefits may be affected appears below
If there is a conflict between this Schedule of Benefits and any summaries provided to you by the Enrolling Group, this
Schedule of Benefits will control.
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 Network Benefits, however, for which you are
responsible for obtaining prior authorization. Services for which you are required to obtain prior authorization are identified
below table within each Covered Health Service category. If you fail to obtain prior authorization as required, Benefits will be
reduced by 50% of the scheduled benefit or $500 per occurrence, whichever is less.
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.
Page 5 of 14
HIOS ID: 49650CT0060008-01
INDIVIDUAL MARKET
When you choose to receive certain Covered Health Services from non-Network providers, you are responsible for
obtaining prior authorization before you receive these services. Note that your obligation to obtain prior
authorization is also applicable when a non-Network provider intends to admit you to a Network facility or refers you
to other Network providers. 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.
To obtain prior authorization, call the telephone number for Customer Care on your ID card. This call starts the
utilization review process.
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.

Ambulance - non-emergent air and ground.

Breast pumps.

Clinical trials.

Diabetes equipment - insulin pumps over $1,000

Durable Medical Equipment over $1,000 in cost either retail purchase cost or cumulative retail rental cost of a single
item.

Formulas/specialized foods.

Genetic Testing, including BRCA Genetic Testing.

Hearing aids that exceed $1,000 in retail purchase cost.

Home health care.

Hospice care - inpatient.

Hospital inpatient care - all scheduled admissions and maternity stays exceeding 48 hours for normal vaginal delivery
or 96 hours for a cesarean section delivery and stays for Complications of Pregnancy exceeding 96 hours for a
cesarean section delivery.

Infertility services.

Lab, X-ray and diagnostics - sleep studies.

Lab, X-ray and major diagnostics - CT, PET Scans, MRI, MRA, Nuclear Medicine and Capsule Endoscopy.

Mental Health Services - inpatient services (including Partial Hospitalization/Day Treatment and services at a
Residential Treatment Facility); Intensive Outpatient Treatment programs; outpatient electro-convulsive treatment;
psychological testing; extended outpatient treatment visits beyond 45 - 50 minutes in duration, with or without
medication management.

Neurobiological disorders - Autism Spectrum Disorder services - inpatient services (including Partial Hospitalization/Day
Treatment and services at a Residential Treatment Facility), Intensive Outpatient Treatment programs; psychological
testing; extended outpatient treatment visits beyond 45 - 50 minutes in duration, with or without medication
management; Applied Behavioral Analysis (ABA).

Obesity surgery.
Page 6 of 14
HIOS ID: 49650CT0060008-01
INDIVIDUAL MARKET

Orthodontia

Pain management.

Pharmaceutical Products - IV infusions only.

Prosthetic devices over $1,000 in cost per device.

Reconstructive procedures, including breast reconstruction surgery following mastectomy and breast reduction surgery.

Rehabilitation services and Chiropractic Treatment -physical therapy, and occupational therapy, and Chiropractic
Treatment, and speech therapy, and pulmonary rehabilitation therapy, and cardiac rehabilitation therapy, and postcochlear implant aural therapy, and cognitive rehabilitation therapy and vision therapy.

Scopic procedures - outpatient diagnostic and therapeutic.

Skilled Nursing Facility and Inpatient Rehabilitation Facility services.

Substance Use Disorder Services - inpatient services (including Partial Hospitalization/Day Treatment and services at a
Residential Treatment Facility; Intensive Outpatient Treatment programs; psychological testing; extended outpatient
treatment visits beyond 45 - 50 minutes in duration, with or without medication management.

Surgery - only for the following outpatient surgeries: cardiac catheterization, pacemaker insertion, implantable
cardioverter defibrillators, diagnostic catheterization, electrophysiology implant and sleep apnea surgeries.

Temporomandibular joint services.

Therapeutics -all outpatient therapeutics] [only for the following services: dialysis, and chemotherapy, and IV infusion,
and radiation oncology, and intensity modulated radiation therapy, and hyperbaric oxygen therapy and MR-guided
focused ultrasound.

Transplants.

Ventricular assist device implantation. You must obtain prior authorization as soon as the possibility of implantation
arises except in cases of Emergency implantations of partial assist devices.
For all other services, when you choose to receive services from non-Network providers, we urge you to confirm with us that
the services you plan to receive are Covered Health Services. That's because in some instances, certain procedures may not
be Medically Necessary or may not otherwise meet the definition of a Covered Health Service, and therefore are excluded. In
other instances, the same procedure may meet the definition of Covered Health Services. By calling before you receive
treatment, you can check to see if the service is subject to limitations or exclusions.
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,
health education, and patient advocacy.
Page 7 of 14
HIOS ID: 49650CT0060008-01
INDIVIDUAL MARKET
Copayment
Copayment is the amount you pay (calculated as a set dollar amount) each time you receive certain Covered Health Services.
When Copayments apply, the amount is listed on the following pages next to the description for each Covered Health Service.
Please note that for Covered Health Services, you are responsible for paying the lesser of:

The applicable Copayment.

The Eligible Expense.
Details about the way in which Eligible Expenses are determined appear below.
Coinsurance
Coinsurance is the amount you pay (calculated as a percentage of Eligible Expenses) each time you receive certain Covered
Health Services.
Details about the way in which Eligible Expenses are determined appear below.
Eligible Expenses
Eligible Expenses are the amount we determine that we will pay for Benefits. For Network Benefits for Covered Health
Services provided by a Network provider, you are not responsible for any difference between Eligible Expenses and the
amount the provider bills. For Non-Network Benefits, you are responsible for paying, directly to the non-Network provider, any
difference between the amount the provider bills you and the amount we will pay for Eligible Expenses. Eligible Expenses are
determined solely in accordance with our reimbursement policy guidelines, as described in the Certificate.
For Network Benefits, Eligible Expenses are based on the following:

When Covered Health Services are received from a Network provider, Eligible Expenses are our contracted fee(s) with
that provider.

When Covered Health Services are received from a non-Network provider as arranged by us, Eligible Expenses are
billed charges unless a lower amount is negotiated or authorized by law.
For Non-Network Benefits, Eligible Expenses are based on either of the following:

When Covered Health Services are received from a non-Network provider, Eligible Expenses are determined, based
on:

Negotiated rates agreed to by the non-Network provider and either us or one of our vendors, affiliates or
subcontractors, at our discretion.

If rates have not been negotiated, then one of the following amounts:
♦
♦
Eligible Expenses are determined based on 110 - 200% of the published rates allowed by the Centers for
Medicare and Medicaid Services (CMS) for Medicare for the same or similar service within the geographic
market, with the exception of the following:

50% of CMS for the same or similar laboratory service.

45% of CMS for the same or similar durable medical equipment, or CMS competitive bid rates.
When a rate is not published by CMS for the service, we use an available gap methodology to determine a
rate for the service as follows:

For services other than Pharmaceutical Products, we use a gap methodology established by
OptumInsight and/or a third party vendor that uses a relative value scale. The relative value scale is
usually based on the difficulty, time, work, risk and resources of the service. If the relative value
scale(s) currently in use become no longer available, we will use a comparable scale(s). We and
OptumInsight are related companies through common ownership by UnitedHealth Group. Refer to
Page 8 of 14
HIOS ID: 49650CT0060008-01
INDIVIDUAL MARKET
our website at www.myuhc.com for information regarding the vendor that provides the applicable
gap fill relative value scale information.

For Pharmaceutical Products, we use gap methodologies that are similar to the pricing methodology
used by CMS, and produce fees based on published acquisition costs or average wholesale price
for the pharmaceuticals. These methodologies are currently created by RJ Health Systems,
Thomson Reuters (published in its Red Book), or UnitedHealthcare based on an internally
developed pharmaceutical pricing resource.

When a rate is not published by CMS for the service and a gap methodology does not apply to the
service, the Eligible Expense is based on 50% of the provider’s billed charge.
We update the CMS published rate data on a regular basis when updated data from CMS becomes available.
These updates are typically implemented within 30 to 90 days after CMS updates its data.
IMPORTANT NOTICE: Non-Network providers may bill you for any difference between the provider's billed
charges and the Eligible Expense described here.
For Emergency Health Services provided by a non-Network provider, the Eligible Expense is a rate agreed upon by the
non-Network provider or determined based upon the higher of:

The median amount negotiated with Network providers for the same service.

110-200% of the published rates allowed by the Centers for Medicare and Medicaid Services (CMS) for the same or
similar service within the geographic market.
When a rate is not published by CMS for the service, we use a gap methodology established by OptumInsight and/or a third
party vendor that uses a relative value scale. The relative value scale is usually based on the difficulty, time, work, risk and
resources of the service. If the relative value scale currently in use becomes no longer available, we will use a comparable
scale(s). We and OptumInsight are related companies through common ownership by UnitedHealth Group. Refer to our
website at www.myuhc.com for information regarding the vendor that provides the applicable gap fill relative value scale
information.
For Pharmaceutical Products, we use gap methodologies that are similar to the pricing methodology used by CMS, and
produce fees based on published acquisition costs or average wholesale price for the pharmaceuticals. These methodologies
are currently created by RJ Health Systems, Thomson Reuters (published in its Red Book), or UnitedHealthcare based on an
internally developed pharmaceutical pricing resource.
When a rate is not published by CMS for the service and a gap methodology does not apply to the service, the Eligible
Expense is based on 50% of the provider's billed charge.
IMPORTANT NOTICE: Non-Network providers may bill you for any difference between the provider's billed charges and the
Eligible Expense described here.

When Covered Health Services are received from a Network provider, Eligible Expenses are our contracted fee(s) with
that provider.
Provider Network
We arrange for health care providers to participate in a Network. Network providers are independent practitioners. They are
not our employees. It is your responsibility to select your provider.
Our credentialing process confirms public information about the providers' licenses and other credentials, but does not assure
the quality of the services provided.
Before obtaining services you should always verify the Network status of a provider. A provider's status may change. You can
verify the provider's status by calling Customer Care. A directory of providers is available online at www.myuhc.com or by
calling Customer Care at the telephone number on your ID card to request a copy.
Page 9 of 14
HIOS ID: 49650CT0060008-01
INDIVIDUAL MARKET
It is possible that you might not be able to obtain services from a particular Network provider. The network of providers is
subject to change. Or you might find that a particular Network provider may not be accepting new patients. If a provider leaves
the Network or is otherwise not available to you, you must choose another Network provider to get Network Benefits.
If you are currently undergoing a course of treatment utilizing a non-Network Physician or health care facility, you may be
eligible to receive transition of care Benefits. This transition period is available for specific medical services and for limited
periods of time. 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.
Do not assume that a Network provider's agreement includes all Covered Health Services. Some Network providers contract
with us to provide only certain Covered Health Services, but not all Covered Health Services. Some Network providers choose
to be a Network provider for only some of our products. Refer to your provider directory or contact us for assistance.
Health Services from Non-Network Providers Paid as Network Benefits
If specific Covered Health Services are not available from a Network provider, you may be eligible for Network Benefits when
Covered Health Services are received from non-Network providers. In this situation, your Network Physician will notify us and,
if we confirm that care is not available from a Network provider, we will work with you and your Network Physician to
coordinate care through a non-Network provider.
Limitations on Selection of Providers
If we determine that you are using health care services in a harmful or abusive manner, or with harmful frequency, your
selection of Network providers may be limited. If this happens, we may require you to select a single Network Physician to
provide and coordinate all future Covered Health Services.
If you don't make a selection within 31 days of the date we notify you, we will select a single Network Physician for you.
If you fail to use the selected Network Physician, Covered Health Services will be paid as Non-Network Benefits.
II. ADDITIONAL INFORMATION: OUTPATIENT PRESCRIPTION DRUGS
Benefits for Prescription Drug Products
Benefits are available for Prescription Drug Products at either a Network Pharmacy or a non-Network Pharmacy and are
subject to Copayments 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 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.
If a Brand-name Drug Becomes Available as a Generic
If a Generic becomes available for a Brand-name Prescription Drug Product, the tier placement of the Brand-name
Prescription Drug Product may change, and therefore your Copayment or Coinsurance may change. You will pay the
Copayment or Coinsurance applicable for the tier to which the Prescription Drug Product is assigned.
Supply Limits
For a single Copayment 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.
Page 10 of 14
HIOS ID: 49650CT0060008-01
INDIVIDUAL MARKET
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.
Prescription Drug Tiers
Prescription Drug Products are categorized into cost tiers. Tier one contains lower cost generic drugs. Tier 2 contains
preferred lower cost brand drugs. Tier 3 typically contains non-preferred brand drugs. Tier 4 typically contains higher cost
brand drugs.
Coupons
We may not permit you to use certain coupons or offers from pharmaceutical manufacturers to reduce your Deductible,
Copayment or Coinsurance. You may access information on which coupons or offers are not permitted through the Internet at
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.
Non-Network Pharmacy Prior Authorization
When Prescription Drug Products are dispensed at a non-Network Pharmacy, you or your Physician are responsible for
obtaining prior authorization from us as required.
Prescription Drug Products which require prior notification are listed below.
Prescription Drug Products which require Notification: Actiq, Anzemet, Avita-Penderm, Avodart, Copegus, DifferinGladerma, Diflucan, Elidel, Emend, Genotropin, Humatrope, Increlex, Infergen, Intron-A, Iplex, Kytril, Lamisil, Lotronex,
Norditropin, Nutropin, Nutropin AQ, Nutropin Depot, PEG-Intron, Pegasys, Proscar, Protopic, Protropin, Provigil,
Raptiva, Regranex, Relenza, Retin-A, Retin-A Micro Ortho, Rebetol, Rebetron, Restasis, Revatio, Roferon, Sporanox,
Saizen, Serostim, Tamiflu, Tazorac, Tracleer, Ventavis, Wellbutrin SR, Wellbutrin XL, Zelnorm, Zofran, Zorbtive.
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. Our contracted pharmacy reimbursement rates (our Prescription Drug Charge) will not be available to you at
a non-Network Pharmacy. You may seek reimbursement from us as described in the Certificate of Coverage (Certificate) in
Section 5: How to File a Claim.
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 (for
Page 11 of 14
HIOS ID: 49650CT0060008-01
INDIVIDUAL MARKET
Prescription Drug Products from a Network Pharmacy) or the Predominant Reimbursement Rate (for Prescription Drug
Products from a non-Network Pharmacy), less the required Copayment or Coinsurance , Ancillary 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.
Step Therapy
Certain Prescription Drug Products for which Benefits are described under this section or Pharmaceutical Products for which
Benefits are described in the 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.
This step therapy process will not require you to use an alternative brand name prescription drug or over-the-counter drug
prior to using a brand name prescription drug that has been prescribed by a licensed physician for pain treatment. We may
require you to use, prior to using a brand name prescription drug prescribed by a licensed physician for pain treatment, a
therapeutically equivalent generic drug.
Prescription Drug Products subject to step therapy requirements: Cesamet.
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 amount you pay for any of the following under this Section will not be included in calculating any Out-of-Pocket Maximum
stated in your Certificate:

The difference between the Predominant Reimbursement Rate and a non-Network Pharmacy's Usual and Customary
Charge for a Prescription Drug Product.

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.
III. ADDITIONAL INFORMATION: PEDIATRIC DENTAL SERVICES
Benefits for comprehensive orthodontic treatment are approved by us, only in those instances that are related to an
identifiable syndrome such as cleft lip and or palate, Crouzon’s syndrome, Treacher-Collins syndrome, Pierre-Robin
syndrome, hemi-facial atrophy, hemi-facial hypertrophy; or other severe craniofacial deformities which result in a physically
handicapping malocclusion as determined by our dental consultants. Benefits are not available for comprehensive orthodontic
treatment for crowded dentitions (crooked teeth), excessive spacing between teeth, temporomandibular joint (TMJ) conditions
and/or having horizontal/vertical (overjet/overbite) discrepancies.
All orthodontic treatment must be prior authorized.
Benefits will be paid in equal monthly installments over the course of the entire orthodontic treatment plan, starting on the date
that the orthodontic bands or appliances are first placed, or on the date a one-step orthodontic procedure is performed.
Benefits for pediatric dental services are limited as outlined below:
Service
Benefit Limit
Page 12 of 14
HIOS ID: 49650CT0060008-01
INDIVIDUAL MARKET
Dental Prophylaxis (Cleanings)
Limited to 2 times per 12 months
Fluoride Treatments
Limited to 2 times per 12 months. Treatment
should be done in conjunction with dental
prophylaxix
Sealants (Protective Coating)
Limited to once per first or second permanent
molar every 36 months
Space Maintainers (Spacers)
Benefit includes all adjustments within 6 months of
installation
Intraoral Bitewing Radiographs (Bitewing X-Ray
Limited to 2 series of films per 12 months
Panorex Radiographs (Full Jaw X-ray) or
Complete Series Radiographs (Full Set of XRays)
Limited to 1 time per 36 months
Periodic Oral Evaluation (Check-Up Exam)
Limited to 2 times per 12 months. Covered as a
separate Benefit only if no other service was done
during the visit other than X-rays.
Amalgam Restorations (Silver Fillings)
Multiple restorations on one surface will be treated
as a single filing
Composite Resin Restorations (Tooth Colored
Fillings)
For anterior (front) teeth only
Periodontal Surgery (Gum Surgery)
Limited 1 quadrant or site per 36 months per
surgical area
Scaling and Root Planing (Deep Cleanings)
Limited to 1 time per quadrant per 24 months
Periodontal Maintenance (Gum Maintenance)
Limited to 4 times per 12 month period in
conjunction with dental prophylaxis following active
and adjunctive periodontal therapy, exclusive of
gross debridement
Simple Extractions (Simple tooth removal)
Limited to 1 time per tooth per lifetime
General Services (including Emergency
Treatment)
Covered as a separate Benefit only if no other
service was done during the visit other than X-rays.
General anesthesia is covered when clinically
necessary.
Occlusal guard limited to 1 guard every 12 months
Inlays/Onlays/Crowns (Partial to Full Crowns)
Limited to 1 time per tooth per 60 months. Covered
only when silver fillings cannot restore the tooth
Fixed Prosthetics (Bridges)
Limited to 1 time per tooth per 60 months. Covered
only when a filling cannot restore the tooth
Removable Prosthetics (Full or partial dentures)
Limited to 1 per 60 months. No additional
allowances for precision or semi-precision
attachments
Relining and Rebasing Dentures
Limited to relining/rebasing performed more than 6
Page 13 of 14
HIOS ID: 49650CT0060008-01
INDIVIDUAL MARKET
months after the initial insertion. Limited to 1 time
per 12 months
Repairs or Adjustments to Full Dentures, Partial
Dentures, Bridges, or Crowns
Limited to repairs or adjustments performed more
than 12 months after the initial insertion. Limited to
1 per 6 months
Implant Placement
Implant Supported Prosthetics
Implant Maintenance Procedures
Includes removal of prosthesis, cleansing of
prosthesis and abutments and reinsertion of
prosthesis
Repair Implant Supported Prosthesis by Report
Abutment Supported Crown (Titanium) or
Retainer Crown for FPD-Titanium
Repair Implant Abutment by Support
Radiographic/Surgical Implant Index by Report
Orthodontic Services
Services or supplies furnished by a Dental Provider
in order to diagnose or correct misalignment of the
teeth or the bite. Benefits are available only when
the service or supply is determined to be medically
necessary
IV. ADDITIONAL INFORMATION: PEDIATRIC VISION SERVICES
Low vision testing is covered on an In-Network basis at 100%.
Low vision therapy is covered on an In-Network basis subject to 25% coinsurance.
Out-of-Network coverage is available for these services subject to the plan Out-of-Network cost share noted above.
Page 14 of 14
HIOS ID: 49650CT0060008-01
Certificate of Coverage Amendment
As described in this Amendment, the Policy is modified as stated below, through the following changes to
the Certificate of Coverage (Certificate).
1. Durable Medical Equipment, Infertility Services, Mental Health Services and
Substance-Related and Addictive Disorders Services in the Certificate Section 1:
Covered Health Services are replaced with the following:
5. Durable Medical Equipment
Durable Medical Equipment that meets each of the following criteria:

Ordered or provided by a Physician for outpatient use primarily in a home setting.

Used for medical purposes.

Not consumable or disposable except as needed for the effective use of covered Durable Medical
Equipment.

Not of use to a person in the absence of a disease or disability.
Benefits under this section include Durable Medical Equipment provided to you by a Physician.
If more than one piece of Durable Medical Equipment can meet your functional needs, Benefits are
available only for the equipment that meets the minimum specifications for your needs.
Examples of Durable Medical Equipment include:

Equipment to assist mobility, such as a standard wheelchair.

A standard Hospital-type bed.

Oxygen and the rental of equipment to administer oxygen (including tubing, connectors and
masks).

Delivery pumps for tube feedings (including tubing and connectors).

Negative pressure wound therapy pumps (wound vacuums).

Braces, including necessary adjustments to shoes to accommodate braces. Braces that stabilize
an injured body part and braces to treat curvature of the spine are considered Durable Medical
Equipment and are a Covered Health Service. Braces that straighten or change the shape of a
body part are orthotic devices, and are excluded from coverage. Dental braces are also excluded
from coverage.

Mechanical equipment necessary for the treatment of chronic or acute respiratory failure (except
that air-conditioners, humidifiers, dehumidifiers, air purifiers and filters and personal comfort items
are excluded from coverage).

Burn garments.

Insulin pumps and all related necessary supplies as described under Diabetes Services.

External cochlear devices and systems. Benefits for cochlear implantation are provided under the
applicable medical/surgical Benefit categories in this Policy.

Hearing aids.
16AMD-IEX-CT
1
Benefits under this section do not include any device, appliance, pump, machine, stimulator, or monitor
We will decide if the equipment should be purchased or rented.

Benefits for repair and replacement do not apply to damage due to misuse, malicious breakage or
gross neglect.

Benefits are not available to replace lost or stolen items.
33. Infertility Services
Services for the treatment of infertility when provided by or under the direction of a Physician.
For the purpose of this benefit, infertility is defined as the condition of a presumably health individual who
is unable to conceive or produce conception or sustain a successful pregnancy during a one-year period.
Coverage must be provided for the expense for the diagnosis and treatment of infertility, including but not
limited to:

Ovulation induction.

Intrauterine insemination.

In-vitro fertilization.

Uterine embryo lavage.

Embryo transfer.

Gamete intra-fallopian transfer (GIFT).

Zygote intra-fallopian transfer (ZIFT).

Low tubal ovum transfer.
Benefits for infertility are limited to the following:

Ovulation induction is limited to a lifetime maximum benefit of four cycles;

Intrauterine insemination is limited to a lifetime maximum benefit of three cycles;

IVF, GIFT, ZIFT and low tubal ovum transfer are limited to a lifetime maximum of two cycles, with
no more than two embryo implantations per cycle;

IVF, GIFT, ZIFT and low tubal ovum transfer are limited to individuals who have not been able to
conceive, produce conception or sustain a successful pregnancy through less expensive and
medically viable infertility treatments unless their Physician determines that such treatment is likely
to be unsuccessful;

Covered Health Services must be performed at facilities that conform to the standards of the
American Society of Reproductive Medicine or the Society of Reproductive Endocrinology and
Infertility.
16AMD-IEX-CT
2
12. Mental Health Services
Mental Health Services include those received on an inpatient basis in a Hospital or an Alternate Facility,
and those received on an outpatient basis in a provider's office or at an Alternate Facility. Certain Mental
Health services require prior authorization. Please refer to your Schedule of Benefits under the heading
authorization.
Benefits include the following services:

General inpatient hospitalization, including in state-operated facilities.

Medically necessary acute treatment services and medically necessary clinical stabilization
services.

General hospital outpatient services, including at state-operated facilities.

Psychiatric inpatient hospitalization, including in state-operated facilities.

Psychiatric outpatient hospital services, including at state-operated facilities.

Intensive outpatient services, including at state-operated facilities.

Partial hospitalization, including at state-operated facilities.

Evidence-based maternal, infant and early childhood home visitation services that are designed to
improve health outcomes for pregnant women, postpartum mothers and newborns and children,
including, but not limited to, for maternal substance use disorders or depression and relationshipfocused interventions for children with mental or nervous conditions or substance use disorders.

Intensive, home-based services designed to address specific mental or nervous conditions in a
child while remediating problematic parenting practices and addressing other family and
educational challenges that affect the child's and family's ability to function.

Intensive, family-based and community-based treatment programs that focus on addressing
environmental systems that impact chronic and violent juvenile offenders.

Evidence-based family-focused therapy that specializes in the treatment of juvenile substance use
disorders and delinquency.

Short-term family therapy intervention and juvenile diversion programs that target at-risk children to
address adolescent behavior problems, conduct disorders, substance use disorders and
delinquency.

Other home-based therapeutic interventions for children.

Chemical maintenance treatment.

Nonhospital inpatient detoxification.

Medically monitored detoxification.

Ambulatory detoxification.

Inpatient services at psychiatric residential treatment facilities. Confinement in a Residential
Treatment Facility must be based on an Individual Treatment Plan prescribed by the attending
physician and approved by the Mental Health/Substance Use Disorder Designee. For the purpose
of this benefit, all of the following criteria must be met:

16AMD-IEX-CT
3


Extended day treatment programs.

Rehabilitation services provided in residential treatment facilities, general hospitals, psychiatric
hospitals or psychiatric facilities.

Observation beds in acute hospital settings.

Psychological and neuropsychological testing conducted by an appropriately licensed health care
provider.

Trauma screening conducted by a licensed behavioral health professional.

Depression screening, including maternal depression screening, conducted by a licensed
behavioral health professional.

Substance use screening conducted by a licensed behavioral health professional.
Special Mental Health Programs and Services
Addictive Disorders Designee may become available to you as a part of your Mental Health Services
Benefit. The Mental Health Services Benefits and financial requirements assigned to these programs or
services are based on the designation of the program or service to inpatient, Partial Hospitalization/Day
Treatment, Intensive Outpatient Treatment, outpatient or a Transitional Care category of Benefit use.
Special programs or services provide access to services that are beneficial for the treatment of your
Mental Illness which may not otherwise be covered under this Policy. You must be referred to such
programs through the Mental Health/Substance-Related and Addictive Disorders Designee, who is
responsible for coordinating your care or through other pathways as described in the program
introductions. Any decision to participate in such a program or service is at the discretion of the Covered
Person and is not mandatory.
24. Substance-Related and Addictive Disorders Services
Substance-Related and Addictive Disorders Services include those received on an inpatient basis in a
Hospital or an Alternate Facility, and those received on an outpatient basis in a provider's office or at an
Alternate Facility. Certain Substance-Related and Addictive Disorders services require prior authorization.
Please refer to your Schedule of Benefits under the heading Covered Health Services which Require
Prior Authorization for a detail list of services that require prior authorization.
Benefits include the following services:

General inpatient hospitalization, including in state-operated facilities.

Medically necessary acute treatment services and medically necessary clinical stabilization
services.

General hospital outpatient services, including at state-operated facilities.

Psychiatric inpatient hospitalization, including in state-operated facilities.

Psychiatric outpatient hospital services, including at state-operated facilities.
16AMD-IEX-CT
4

Intensive outpatient services, including at state-operated facilities.

Partial hospitalization, including at state-operated facilities.

Evidence-based maternal, infant and early childhood home visitation services that are designed to
improve health outcomes for pregnant women, postpartum mothers and newborns and children,
including, but not limited to, for maternal substance use disorders or depression and relationshipfocused interventions for children with mental or nervous conditions or substance use disorders.

Intensive, home-based services designed to address specific mental or nervous conditions in a
child while remediating problematic parenting practices and addressing other family and
educational challenges that affect the child's and family's ability to function.

Intensive, family-based and community-based treatment programs that focus on addressing
environmental systems that impact chronic and violent juvenile offenders.

Evidence-based family-focused therapy that specializes in the treatment of juvenile substance use
disorders and delinquency.

Short-term family therapy intervention and juvenile diversion programs that target at-risk children to
address adolescent behavior problems, conduct disorders, substance use disorders and
delinquency.

Other home-based therapeutic interventions for children.

Chemical maintenance treatment.

Nonhospital inpatient detoxification.

Medically monitored detoxification.

Ambulatory detoxification.

Inpatient services at psychiatric residential treatment facilities. Confinement in a Residential
Treatment Facility must be based on an Individual Treatment Plan prescribed by the attending
physician and approved by the Mental Health/Substance Use Disorder Designee. For the purpose
of this benefit, all of the following criteria must be met:



Extended day treatment programs.

Rehabilitation services provided in residential treatment facilities, general hospitals, psychiatric
hospitals or psychiatric facilities.

Observation beds in acute hospital settings.

Psychological and neuropsychological testing conducted by an appropriately licensed health care
provider.

Trauma screening conducted by a licensed behavioral health professional.

Depression screening, including maternal depression screening, conducted by a licensed
behavioral health professional.

Substance use screening conducted by a licensed behavioral health professional.
16AMD-IEX-CT
5
Special-Related and Addictive Disorders Programs and Services
Addictive Disorders Designee may become available to you as a part of your Substance-Related and
Addictive Disorders Services Benefit. The Substance-Related and Addictive Disorders Services Benefits
and financial requirements assigned to these programs or services are based on the designation of the
program or service to inpatient, Partial Hospitalization/Day Treatment, Intensive Outpatient Treatment,
outpatient or a Transitional Care category of Benefit use. Special programs or services provide access to
services that are beneficial for the treatment of your substance-related and addictive disorders which may
not otherwise be covered under this Policy. You must be referred to such programs through the Mental
Health/Substance-Related and Addictive Disorders Designee, who is responsible for coordinating your
care or through other pathways as described in the program introductions. Any decision to participate in
such a program or service is at the discretion of the Covered Person and is not mandatory.
2. The following Benefit for Telehealth Services is added to Section 1: Covered
Health Services:
Telehealth Services
Telehealth services are covered when services are received for the diagnosis, prevention, treatment, cure
or relief of a physical or mental health conditions, illness, injury or disease. These services are covered
to the same extent that the same services would be covered if received during a face to face
consultation. The cost share for Telehealth services will be based on the type of provider who rendered
the services (Primary Care Physician or Specialist), as outlined in your Summary of Benefits. If these
services are received from a network Telehealth provider, they will be covered at the network level of
benefits, and if received from a non-network provider, they will be covered at the non-network level of
benefits.
For purposes of this Benefit, “Telehealth” means the mode of delivering health care or other health
services via information and communication technologies to facilitate the diagnosis, consultation and
treatment, education, care management and self-management of a covered member’s physical and
mental health and includes:

interaction between the patient at an originating site and the Telehealth provider at a distant
site, and

synchronous interactions, synchronous store and forward transfers or remote monitoring.
Telehealth does not include the use of facsimile, audio-only telephone, texting or electric mail.
3. Section 2: Exclusions and Limitations is modified by replacing the exclusions
for Drugs, Mental Health, Neurobiological Disorders - Autism Spectrum
Disorder,Reproduction, Substance Use Disorders and Vision and Hearing with
the following exclusions:
D. Drugs
1.
Prescription drug products for outpatient use that are filled by a prescription order or refill.
2.
Self-injectable medications. This exclusion does not apply to medications which, due to their
characteristics (as determined by us), must typically be administered or directly supervised by a
qualified provider or licensed/certified health professional in an outpatient setting.
16AMD-IEX-CT
6
3.
Non-injectable medications given in a Physician's office. This exclusion does not apply to noninjectable medications that are required in an Emergency and consumed in the Physician's office.
4.
Over-the-counter drugs and treatments, except for those preventive care drugs covered under the
Affordable Care Act.
5.
Growth hormone therapy.
6.
A Pharmaceutical Product that contains (an) active ingredient(s) available in and therapeutically
equivalent (having essentially the same efficacy and adverse effect profile) to another covered
Pharmaceutical Product. Such determinations may be made up to six times during a calendar year,
unless medically necessary.
7.
A Pharmaceutical Product that contains (an) active ingredient(s) which is (are) a modified version
of and therapeutically equivalent (having essentially the same efficacy and adverse effect profile) to
another covered Pharmaceutical Product. Such determinations may be made up to six times during
a calendar year, unless medically necessary.
8.
Benefits for Pharmaceutical Products for the amount dispensed (days' supply or quantity limit)
H. Mental Health
directly below apply to services described under Mental Health Services in Section 1: Covered Health
Services.
1.
2.
Mental Health Services as treatment for a primary diagnosis of sexual dysfunction, communication
disorders, motor disorders and other disorders with a known physical basis.
3.
4.
Educational services that are focused on primarily building skills and capabilities in communication,
social interaction and learning.
5.
6.
Motor disorders and primary communication disorders as defined in the current edition of the
7.
Intellectual disabilities as a primary diagnosis defined in the current edition of the Diagnostic and
8.
Autism spectrum disorder as a primary diagnosis defined in the current edition of the Diagnostic
and Statistical Manual of the American Psychiatric Association. Benefits for autism spectrum
disorder as a primary diagnosis are described under Neurobiological Disorders - Autism Spectrum
Disorder Services in Section 1: Covered Health Services.
9.
Mental Health Services as a treatment for other conditions that may be a focus of clinical attention
as listed in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric
Association.
10.
11.
following:
16AMD-IEX-CT
7


Described as a Covered Health Service in this Certificate under Section 1: Covered Health

Not otherwise excluded in this Certificate under Section 2: Exclusions and Limitations.
I. Neurobiological Disorders - Autism Spectrum Disorder
directly below apply to services described under Neurobiological Disorders - Autism Spectrum Disorder
Services in Section 1: Covered Health Services.
1.
Any treatments or other specialized services designed for Autism Spectrum Disorder that are not
backed by credible research demonstrating that the services or supplies have a measurable and
beneficial health outcome and therefore considered Experimental or Investigational or Unproven
Services.
2.
Intellectual disability as the primary diagnosis defined in the current edition of the Diagnostic and
3.
4.
Learning, motor disorders and communication disorders as defined in the current edition of the
Diagnostic and Statistical Manual of the American Psychiatric Association and which are not a part
of Autism Spectrum Disorder.
5.
6.
7.
following:



O. Reproduction
1.
Health services and associated expenses for infertility treatments for Covered Persons, 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.
2.
Surrogate parenting, donor eggs, donor sperm and host uterus.
3.
The reversal of voluntary sterilization.
4.
Fetal reduction surgery.
16AMD-IEX-CT
8
Q. Substance Use Disorders
directly below apply to services described under Substance Use Disorder Services in Section 1: Covered
Health Services.
1.
2.
Educational services that are focused on primarily building skills and capabilities in communication,
social interaction and learning.
3.
Substance-induced sexual dysfunction disorders and substance-induced sleep disorders.
4.
Gambling disorders.
5.
6.
following:



U. Vision and Hearing
Please Note: The following vision exclusion does not apply to Pediatric Vision services. Refer to
Section 11: Pediatric Vision Care Services for coverage information.
1.
Purchase cost and fitting charge for eyeglasses and contact lenses.
2.
Routine vision examinations, including refractive examinations to determine the need for vision
correction.
3.
Implantable lenses used only to correct a refractive error (such as Intacs corneal implants).
4.
Eye exercise or vision therapy.
5.
Surgery that is intended to allow you to see better without glasses or other vision correction.
Examples include radial keratotomy, laser and other refractive eye surgery.
16AMD-IEX-CT
9
4. Section 6: Questions, Complaints and Appeals is replaced in its
entirety with the following:
Section 6: Questions, Complaints and Appeals
To resolve a question, complaint, or appeal, just follow these steps:
Information Requests
A Covered Person or Authorized Representative is entitled to request free of charge copies of all
documents, communications, information, and evidence, including citations to any medical journals,
regarding the Covered Person’s claim for benefits that the Covered Person had neither submitted nor
received at the time of the initial decision.
We will provide copies by facsimile, electronic means, or any other expeditious method available no later
than five business days after receipt of such request (or within one calendar day if related to an Urgent
Care Request).
Internal Review of Adverse Determinations Involving Utilization Review
General Information:
1.
A health plan providing benefits for an ongoing course of treatment is required to provide continued
coverage without liability to the Covered Person until the Covered Person has been notified of the
Grievance review decision. A health plan cannot reduce or terminate benefits for an ongoing
course of treatment without providing advance notice and an opportunity for advance review.
2.
When conducting a review of an Adverse Determination, We will ensure that such review is
conducted in a manner to ensure the independence and impartiality of the Clinical Peer(s) involved
in making the review decision.
3.
Covered Persons have the right to submit written comments, documents, records, and other
information relating to the claim for benefits.
4.
All comments, documents, records and other information submitted by the Covered Person relating
to the claim for benefits, regardless of whether such information was submitted or considered in
making the initial determination, will be considered in the Grievance review.
5.
Covered Persons have the right to review the claim file and to present evidence and testimony as
part of the internal review process.
6.
The Covered Person will receive from Us, as soon as possible, any new or additional evidence
considered by the reviewer. We will give the Covered Person 10 calendar days to respond to the
new information before making a determination, unless the state turnaround time for response is
due in less than 10 days. If the state turnaround time is less than 10 days, the Covered Person will
have the option of delaying the determination for a reasonable period of time to respond to the new
information.
7.
The Covered Person will receive from Us, as soon as possible, any new or additional medical
rationale considered by the reviewer. We will give the Covered Person 10 calendar days to
respond to the new medical rationale before making a determination, unless the state turnaround
time for response is due in less than 10 days. If the state turnaround time is less than 10 days, the
Covered Person will have the option of delaying the determination for a reasonable period of time
to respond to the new medical rationale.
8.
If We fail to strictly adhere to the requirements of Our Grievance procedures with respect to
receiving and resolving Grievances involving an Adverse Determination, the Covered Person will
be deemed to have exhausted the internal Grievance process and may file a request for an
16AMD-IEX-CT
10
external review, regardless of whether We assert that We substantially complied with the
requirements of this section, or that any error we committed was insignificant.
9.
A Covered Person who has exhausted Our internal Grievance process with respect to a Grievance
involving an Adverse Determination may, in addition to filing a request for an external review,
pursue any available remedies under state or federal law on the basis that We failed to provide a
reasonable internal Grievance process that would yield a decision on the merits of the claim.
Non-Urgent Care Reviews
1.
Request: A Covered Person may file a Grievance in writing with us within 180 calendar days after
the Covered Person receives the notice of an Adverse Determination.
2.
Reviewer’s Requirements: We will designate an appropriate Clinical Peer(s) who was not
previously involved in the initial Adverse Determination to conduct a review.
3.
Resolution Timeframe: We will notify the Covered Person in writing or by electronic means, of Our
decision within a reasonable period of time appropriate to the Covered Person’s medical condition,
but not later than:
4.

30 calendar days after We receive the Grievance for Prospective Review and Concurrent
Review Adverse Determination decisions, regardless of if all of the information necessary for
Us to make the determination accompanies the Grievance; or

60 calendar days after We receive the Grievance for Retrospective Review Adverse
Determination decisions, regardless of if all of the information necessary for us to make the
determination accompanies the Grievance.
Notification of Determination: The notice must include:

Information sufficient to identify the claim involved with respect to the Grievance, including
the date of service, if applicable, the health care professional and the claim amount;

The titles and qualifying credentials of the Clinical Peer(s) participating in the review
process, without regard to whether the advice was relied upon in making the determination;

A statement of the Clinical Peer’s or Peers’ understanding of the Covered Person’s
Grievance;

The Clinical Peer’s or Peers’ decision in clear terms and the health benefit plan contract
basis or scientific or clinical rationale for such decision in sufficient detail for the Covered
Person to respond further to Our position. The explanation of the scientific or clinical
rationale used to make the determination will apply the terms of the health benefit plan to the
Covered Person’s medical circumstances or indicate that it will be provided free of charge
upon request and include instructions for requesting such copy;

Reference to the evidence or documentation used as the basis for the decision;

If the Adverse Determination is upheld or modified:
♦
The specific reason(s) for the Final Adverse Determination, including the denial code
and its corresponding meaning, as well as a description of the health plan’s standard,
if any, that was used in reaching the denial;
♦
The following or a substantially similar statement: “We have denied your request for
benefit approval for a health care service or course of treatment. You may have the
right to have our decision reviewed by health care professionals who have no
association with us by submitting a request for external review to the office of the
Insurance Commissioner, if our decision involved making a judgment as to the
medical necessity, appropriateness, health care setting, level of care or effectiveness
of the health care service or treatment you requested.”
♦
A statement that the Covered Person may receive from Us, free of charge and upon
request, reasonable access to and copies of, all documents, records,
16AMD-IEX-CT
11
communications, and other information and evidence not previously provided
regarding the Adverse Determination under review;
♦
If the Final Adverse Determination is based on Our internal rule, guideline, protocol, or
other similar criterion either the specific rule, guideline, protocol, or other similar
criterion, or a statement that a copy of such information will be provided to the
Covered Person free of charge upon request and instructions for requesting such
copy;
♦
The diagnosis and procedure codes with their corresponding meanings, or an
explanation that the diagnosis and/or procedure codes are available upon request;
♦
A description of external appeal rights and the procedures for initiating an external
review, including a description of expedited review;
♦
A statement explaining the right of the Covered Person to contact the commissioner’s
office or the Office of the Healthcare Advocate at any time for assistance or, to file a
civil suit in a court of competent jurisdiction upon completion of the internal Grievance
process;
♦
The contact information for the commissioner’s office or the Office of the Healthcare
Advocate;
♦
A statement the Covered Person may have a right to bring a civil action under federal
law;
♦
A culturally linguistic statement based upon the Covered Person’s county or state of
residence that provides for oral translation of the determination, if applicable;
♦
If applicable, the following statement: “You and your plan may have other voluntary
alternative dispute resolution options such as mediation. One way to find out what
may be available is to contact your state Insurance Commissioner.”
♦
A statement that all internal appeals have been exhausted; and
♦
Connecticut’s “A Consumer’s Guide to Appealing Health Insurance Denials” and
Request for External Review form.
Reviews of Urgent Care Requests:
1.
Request: For prospective or concurrent Urgent Care Requests, a Covered Person may request an
expedited review orally or in writing.
2.
General Information: All necessary information, including Our decision, must be transmitted
between Us and the Covered Person by telephone, facsimile, electronic means or any other
expeditious method available.
3.
Reviewer’s Requirements: We will designate an appropriate Clinical Peer(s) to conduct the review
who was not previously involved in the initial Adverse Determination involving Utilization Review.
4.
Resolution Timeframe: We will notify the Covered Person in writing or by electronic means of Our
decision within:


24 hours after We receive the Grievance involving expedited review requests of:
♦
A health care service or course of treatment for a substance abuse disorder or cooccurring mental disorder; or
♦
Inpatient services, partial hospitalization, residential treatment, or intensive outpatient
services needed to keep a Covered Person from requiring an inpatient setting in
connection with a mental disorder.
For all other Urgent Care Requests, a reasonable period of time appropriate to the Covered
Person’s medical condition, but not later than 72 hours after We receive the Grievance,
16AMD-IEX-CT
12
regardless of if all of the information necessary for us to make the determination
accompanies the Grievance.
5.

Information sufficient to identify the claim involved with respect to the Grievance, including
the date of service, if applicable, the health care professional and the claim amount;

The titles and qualifying credentials of the Clinical Peer(s) participating in the review
process, without regard to whether the advice was relied upon in making the determination;

A statement of the Clinical Peer’s or Peers’ understanding of the Covered Person’s
Grievance;

The Clinical Peer’s or Peers’ decision in clear terms and the health benefit plan contract
basis or scientific or clinical rationale for such decision in sufficient detail for the Covered
Person to respond further to Our position. The explanation of the scientific or clinical
rationale used to make the determination will apply the terms of the health benefit plan to the
Covered Person’s medical circumstances or indicate that it will be provided free of charge
upon request and include instructions for requesting such copy;

Reference to the evidence or documentation used as the basis for the decision;

If the Adverse Determination is upheld or modified:
♦
The specific reason(s) for the Final Adverse Determination, including the denial code
and its corresponding meaning, as well as a description of Our standard, if any, that
was used in reaching the denial;
♦
The following or a substantially similar statement: “We have denied your request for
benefit approval for a health care service or course of treatment. You may have the
right to have our decision reviewed by health care professionals who have no
association with us by submitting a request for external review to the office of the
Insurance Commissioner, if our decision involved making a judgment as to the
Medical Necessity, appropriateness, health care setting, level of care or effectiveness
of the health care service or treatment you requested.”
♦
A statement that the Covered Person may receive from Us, free of charge and upon
request, reasonable access to and copies of, all documents, records,
communications, and other information and evidence not previously provided
regarding the Adverse Determination under review;
♦
If the Final Adverse Determination is based on Our internal rule, guideline, protocol, or
other similar criterion either the specific rule, guideline, protocol, or other similar
criterion, or a statement that a copy of such information will be provided to the
Covered Person free of charge upon request and instructions for requesting such
copy;
♦
The diagnosis and procedure codes with their corresponding meanings, or an
explanation that the diagnosis and/or procedure codes are available upon request;
♦
A description of external appeal rights and the procedures for initiating an external
review, including a description of expedited review;
♦
A statement explaining the right of the Covered Person to contact the commissioner’s
office or the Office of the Healthcare Advocate at any time for assistance or, to file a
civil suit in a court of competent jurisdiction upon completion of the internal Grievance
process;
♦
The contact information for the commissioner’s office or the Office of the Healthcare
Advocate;
♦
A statement the Covered Person may have a right to bring a civil action under federal
law;
16AMD-IEX-CT
13
♦
♦
If applicable, the following statement: “You and your plan may have other voluntary
alternative dispute resolution options such as mediation. One way to find out what
may be available is to contact your state Insurance Commissioner.”
♦
♦
Connecticut’s “A Consumer’s Guide to Appealing Health Insurance Denials” and
Request for External Review form.
Internal Review of All Other Adverse Determinations
This section applies to Grievances related to:
1.
Rescission;
2.
Availability of health care services; and
3.
Claims payment, handling, or reimbursement.
Request: A Covered Person may file a Grievance in writing with Us within 180 calendar days after the
Covered Person receives the notice of an Adverse Determination.
1.
A health plan providing benefits for an ongoing course of treatment is required to provide continued
coverage pending the outcome of the Grievance review. A health plan cannot reduce or terminate
benefits for an ongoing course of treatment without providing advance notice and an opportunity for
advance review.
2.
Covered Persons have the right to submit written comments, documents, records, and other
information relating to the claim for benefits.
3.
Covered Persons have the right to review the claim file and to present evidence and testimony as
part of the internal review process.
4.
All comments, documents, records and other information submitted by the Covered Person relating
to the claim for benefits, regardless of whether such information was submitted or considered in
making the initial determination, will be considered in the Grievance review.
5.
The Covered Person will receive from Us, as soon as possible, any new or additional evidence
considered by the reviewer. We will give the Covered Person 10 calendar days to respond to the
new information before making a determination, unless the state turnaround time for response is
due in less than 10 days. If the state turnaround time is less than 10 days, the Covered Person will
have the option of delaying the determination for a reasonable period of time to respond to the new
information.
6.
The Covered Person will receive from Us, as soon as possible, any new or additional medical
rationale considered by the reviewer. We will give the Covered Person 10 calendar days to
respond to the new medical rationale before making a determination, unless the state turnaround
time for response is due in less than 10 days. If the state turnaround time is less than 10 days, the
Covered Person will have the option of delaying the determination for a reasonable period of time
to respond to the new medical rationale.
7.
If We fail to strictly adhere to the requirements of Our Grievance procedures with respect to
receiving and resolving Grievances involving an Adverse Determination, the Covered Person will
be deemed to have exhausted the internal Grievance process and may file a request for an
external review, regardless of whether We assert that We substantially complied with the
requirements of this section, or that any error we committed was insignificant.
Acknowledgment: We must notify the Covered Person not later than three business days after We
receive the Grievance that the Covered Person is entitled to submit written material to be considered by
16AMD-IEX-CT
14
us. The acknowledgment must include the name, address, and telephone number of the individual or the
organizational unit designated to coordinate the review on Our behalf.
Reviewer’s Requirements:
1.
If the Grievance involves a Rescission, a panel of individuals who were not involved in the original
Adverse Determination will review the Grievance.
2.
If the Grievance involves a decision based in whole or in part on a medical judgment, We will
consult with a health care professional who has appropriate training and experience in the field of
medicine involved in the medical issue and who was not consulted in connection with the original
decision.
3.
For all other Grievances, We will designate an impartial person(s) who was not involved in making
the original decision and who is not a subordinate of the original reviewer to conduct the review.
decision not later than 20 business days after We received the Grievance. This timeframe can be
extended by Us for up to 10 business days due to circumstances beyond Our control if We provide written
notice to the Covered Person on or before the 20th day. The notice must include the reasons for the
delay.
1.
The titles and qualifying credentials of the individual(s) participating in the review process, without
regard to whether the advice was relied upon in making the determination;
2.
A statement of the reviewer(s) understanding of the Covered Person’s Grievance;
3.
The reviewer(s) decision in clear terms and the health benefit plan contract basis for such decision
in sufficient detail for the Covered Person to respond further to Our position;
4.
Reference to the documents, communications, information, and evidence used as the basis for the
decision;
5.
If the decision is upheld or modified:

The Covered Person may have a right to bring a civil action under state or federal law;

The date of service;

The health care provider’s name;

The claim amount;

The diagnosis and procedure codes with their corresponding meanings, or an explanation
that the diagnosis and/or procedure codes are available upon request;

Our denial code with corresponding meaning;

A description of any standard used, if any, in denying the claim;

The following or a substantially similar statement: “We have denied your request for benefit
approval for a health care service or course of treatment. You may have the right to have
our decision reviewed by health care professionals who have no association with us by
submitting a request for external review to the office of the Insurance Commissioner, if our
decision involved making a judgment as to the Medical Necessity, appropriateness, health
care setting, level of care or effectiveness of the health care service or treatment you
requested.”

A statement that the Covered Person may receive from Us, free of charge and upon request,
reasonable access to and copies of, all documents, records, communications, and other
information and evidence that is the subject of the Adverse Determination;

A description of external appeal rights and the procedures for initiating an external review,
including a description of expedited review;
16AMD-IEX-CT
15

A statement providing the contact information and explaining the right of the Covered Person
to contact the commissioner’s office or the Office of the Healthcare Advocate at any time for
assistance;



Connecticut’s “A Consumer’s Guide to Appealing Health Insurance Denials” and Request for
External Review form.
Internal Review of All Other Grievances
This section applies to Grievances related to:
1.
Delivery of care;
2.
Quality of care; and
3.
The contractual relationship between a Covered Person and Us excluding Rescission.
Request: A Covered Person may file a Grievance in writing with Us within 180 calendar days after the
Covered Person receives notification of the determination giving rise to the Grievance.
Acknowledgment: We must notify the Covered Person not later than three business days after We
receive the Grievance that the Covered Person is entitled to submit written material to be considered by
Us. The acknowledgment must include the name, address, and telephone number of the individual or the
organizational unit designated to coordinate the review on Our behalf.
Reviewer’s Requirements: We will designate an individual(s) to conduct a review of the Grievance. The
individual(s) will not be the same individual(s) who denied the claim or handled the matter that is the
subject of the Grievance.
decision not later than 20 business days after We received the Grievance. This timeframe can be
extended by Us for up to 10 business days due to circumstances beyond Our control if We provide written
notice to the Covered Person on or before the 20th day. The notice must include the reasons for the
delay.
1.
The titles and qualifying credentials of the individual(s) participating in the review process;
2.
A statement of the reviewer(s) understanding of the Covered Person’s Grievance;
3.
The reviewer(s) decision in clear terms and the health benefit plan contract basis for such decision
in sufficient detail for the Covered Person to respond further to Our position; and
4.
Reference to the evidence or documentation used as the basis for the decision.
External Reviews
1.
An external review may be requested for the denial, reduction, termination or failure to make
payment under the health benefit plan on the basis that:

The benefit does not meet Our requirements for Medical Necessity, appropriateness, health
care setting, level of care, effectiveness of the health care service; or

We consider the drug, procedure or therapy to be experimental and or/investigational; or

We have made an Adverse Determination involving eligibility to participate in the health
benefit plan; or
16AMD-IEX-CT
16

We have rescinded coverage due to an alleged fraudulent act, practice or omission or the
intentional misrepresentation of material fact.
2.
A Covered Person may file a request for an external review in writing to the commissioner within
120 days after receipt of the Adverse Determination or Final Adverse Determination.
3.
All requests for external review must be accompanied by a filing fee of $25, except that no Covered
Person will pay more than $75 in a calendar year.

If the commissioner finds that the Covered Person is indigent or unable to pay the filing fee,
the commissioner will waive such fee.

The commissioner will refund any paid filing fee to the Covered Person or the health care
professional if the Final Adverse Determination that is the subject of the external review
request is reversed or revised.
4.
Except as otherwise provided, a Covered Person cannot file a request for an external review until
the Covered Person has exhausted Our internal appeal process.
5.
We may waive Our internal appeal process and the requirement for a Covered Person to exhaust
such process prior to filing a request for an external review.
6.
We will pay the Independent Review Organization (IRO) for the cost of conducting the review.
7.
A Covered Person cannot file a subsequent request for an external review or expedited external
review that involves the same Adverse Determination or Final Adverse Determination for which the
covered person already received an external review decision.
8.
An external review decision is binding on Us and the Covered Person, except to the extent such
We or the Covered Person has other remedies available under federal or state law.
Expedited External Review Request:
1.
A Covered Person may file a request for an expedited external review of an Adverse Determination
or a Final Adverse Determination with the commissioner at the same time the Covered Person
receives:


An Adverse Determination, if the Covered Person has filed a request for an expedited
internal review of the Adverse Determination and:
♦
The Covered Person has a medical condition for which the time period for completion
of an expedited internal review of the Adverse Determination would seriously
jeopardize the life or health of the Covered Person or would jeopardize the Covered
Person’s ability to regain maximum function; or
♦
The denial of coverage is based on a determination that the recommended or
requested health care service or treatment is experimental or investigational and the
Covered Person’s treating health care professional certifies in writing that such
recommended or requested health care service or treatment would be significantly
less effective if not promptly initiated; or
A Final Adverse Determination if:
♦
The Covered Person has a medical condition for which the time period for completion
of a standard external review would seriously jeopardize the life or health of the
Covered Person or would jeopardize the Covered Person’s ability to regain maximum
function;
♦
The Final Adverse Determination concerns an admission, availability of care,
continued stay or health care service for which the Covered Person received
Emergency Services but has not been discharged from a facility; or
♦
The denial of coverage is based on a determination that the recommended or
requested health care service or treatment is experimental or investigational and the
16AMD-IEX-CT
17
Covered Person’s treating health care professional certifies in writing that such
recommended or requested health care service or treatment would be significantly
less effective if not promptly initiated.
2.
An expedited external review will not be provided for a Retrospective Review request of an
Adverse Determination or a Final Adverse Determination.
Procedure:
1.
Within one business day after the commissioner receives a request that is complete, the
commissioner will send a copy of the request to the health plan that issued the Adverse
Determination or Final Adverse Determination.
2.
Within five business days (one calendar day for expedited) after We receive the copy of an external
review request from the commissioner, We will complete a preliminary review of the request to
determine whether:

The individual is or was a Covered Person under the health benefit plan at the time the
health care service was requested or provided;

The health care service that is the subject of the Adverse Determination and Final Adverse
Determination is a covered service under the Covered Person’s health benefit plan but for
Our determination that the health care service is not covered because it does not meet Our
requirements for Medical Necessity, appropriateness, health care setting, level of care or
effectiveness;

If the health care service or treatment is experimental or investigational:
♦
Is a covered benefit under the Covered Person’s health benefit plan but for Our
determination that the service or treatment is experimental or investigational for a
particular medical condition;
♦
Is not explicitly listed as an excluded benefit under the Covered Person’s health
benefit plan;
♦
The Covered Person’s treating health care professional has certified that one of the
following situations is applicable:
♦
16AMD-IEX-CT

Standard health care services or treatments have not been effective in
improving the medical condition of the Covered Person;

Standard health care services or treatments are not medically appropriate for
the Covered Person; or

There is no available standard health care service or treatment covered by Us
that is more beneficial than the recommended or requested health care service
or treatment; and
The Covered Person’s treating health care professional:

Has recommended a health care service or treatment that the health care
professional certifies, in writing, is likely to be more beneficial to the Covered
Person, in the health care professional’s opinion, than any available standard
health care services or treatments; or

Is a licensed, board certified or board eligible health care professional qualified
to practice in the area of medicine appropriate to treat the Covered Person’s
condition and has certified in writing that scientifically valid studies using
accepted protocols demonstrate that the health care service or treatment
requested by the Covered Person that is the subject of the Final Adverse
Determination is likely to be more beneficial to the Covered Person than any
available standard health care services or treatments;
18
3.
4.

The Covered Person has exhausted Our internal Grievance process or the Covered Person
has filed a request for an expedited external review; and

The Covered Person has provided all the information and forms required to process an
external review or an expedited external review.
Within one business day after the preliminary review of an external review request is completed
(the day the preliminary review is completed for expedited), We will notify the commissioner and
the Covered Person in writing whether the request for an external review is:

Complete and eligible for external review;

Not complete and will specify what information or materials are needed to perfect the
request; or

Not eligible for external review and include the reasons for its ineligibility and a statement
that this determination may be appealed to the commissioner.
Within one business day (one calendar day for expedited) after receipt of the notice from Us that
the request is eligible for external review or expedited external review, the commissioner will:

Randomly assign an IRO to conduct the review;

Notify Us of the name of the assigned IRO; and

Notify the Covered Person in writing of the request’s eligibility and acceptance for external
review or expedited external review. The commissioner will advise the Covered Person that
they may submit additional information to the assigned IRO within five business days after
receipt of the commissioner notice. The IRO is not required to, but may, accept and
consider additional information submitted after five business days.
5.
Within five business days (one calendar day for expedited) after We receive notice of the IRO
assignment, We will provide the IRO the documents and any information We or Our designee
utilization review company considered in making the Adverse Determination or the Final Adverse
Determination.
6.
Within one business day after receiving any information submitted by the Covered Person, the IRO
will forward the information to Us.

Upon the receipt of any information, We may reconsider Our Adverse Determination or the
Final Adverse Determination.

If We decide to reverse Our Adverse Determination or Final Adverse Determination, We will
notify the commissioner, the assigned IRO, and the Covered Person in writing of such
decision within one business day after making the decision.
Resolution Timeframe and Notification of Determination:
1.
The IRO will notify the commissioner, Us, and the Covered Person in writing of its decision to
uphold, reverse or revise the Adverse Determination or Final Adverse Determination, not later than:


For standard external reviews:
♦
20 calendar days after the IRO receives the assignment from the commissioner if the
review involves a determination that the recommended or requested health care
service or treatment is experimental or investigational; or
♦
45 calendar days after the IRO receives the assignment from the commissioner for all
other determinations.
For expedited external reviews as expeditiously as the Covered Person’s medical condition
requires, but not later than:
16AMD-IEX-CT
19
2.
♦
5 calendar days after the IRO receives the assignment from the commissioner if the
review involves a determination that the recommended or requested health care
service or treatment is experimental or investigational; or
♦
24 hours after the IRO receives the assignment from the commissioner if the review
involves a health care service or course of treatment for a substance abuse disorder
or for a mental disorder; or
♦
72 hours after the IRO receives the assignment from the commissioner for all other
determinations.
Upon the receipt of a notice of the IRO’s decision to reverse or revise an Adverse Determination or
Final Adverse Determination, We will immediately approve the coverage that was the subject of the
Adverse Determination or Final Adverse Determination.
Connecticut Contact Information
State of Connecticut Insurance Department
Consumer Affairs Unit
PO Box 816
Phone: (860) 297-3900 or (800) 203-3447
Fax: (860) 297-3872
[email protected]
State of Connecticut
Office of the Healthcare Advocate
PO Box 1543
Hartford, CT 06144
Phone: (866) 466-4446
Fax: (860) 331-2499
www.ct.gov/oha
Email: [email protected]
Definitions
As used in this section, the following terms have the meanings indicated:
Adverse Determination 1.
2.
The denial, reduction, termination or failure to provide or make payment, in whole or in part, for a
benefit under the health benefit plan requested by a Covered Person or a Covered Person’s
treating health care professional, based on a determination by Us or Our designee utilization
review company:

That, based upon the information provided upon application of any Utilization Review
technique, such benefit does not meet Our requirements for Medical Necessity,
appropriateness, health care setting, level of care or effectiveness; or is determined to be
experimental or investigational;

Of a Covered Person’s eligibility to participate in the health benefit plan, including a
Rescission of coverage determination;
Any Prospective Review, Concurrent Review or Retrospective Review determination that denies,
reduces or terminates or fails to provide or make payment in whole or in part, for a benefit under
16AMD-IEX-CT
20
the health benefit plan requested by a Covered Person or a Covered Person’s treating health care
professional.
Authorized Representative 1.
A person to whom a Covered Person has given express written consent to represent the Covered
Person for the purposes of these procedures;
2.
A person authorized by law to provide substituted consent for a Covered Person;
3.
A family member of the Covered Person or the Covered Person’s treating health care professional
when the Covered Person is unable to provide consent;
4.
A health care professional when the Covered Person’s health benefit plan requires that a request
for a benefit under the plan be initiated by the health care professional; or
5.
In the case of an Urgent Care Request, a health care professional with knowledge of the Covered
Person’s medical condition.
Clinical Peer - a Physician or other health care professional who:
1.
Holds a nonrestricted license in a state of the United States and in the same or similar specialty as
typically manages the medical condition, procedure or treatment under review; and
2.
For a review concerning:


A child or adolescent substance use disorder or a child or adolescent mental disorder, holds:
♦
A national board certification in child and adolescent psychiatry; or
♦
A doctoral level psychology degree with training and clinical experience in the
treatment of child and adolescent substance use disorder or child and adolescent
mental disorder, as applicable, or
An adult substance use disorder or an adult mental disorder, holds:
♦
A national board certification in psychiatry; or
♦
A doctoral level psychology degree with training and clinical experience in the
treatment of adult substance use disorders or adult mental disorders, as applicable.
Concurrent review - Utilization Review conducted during a patient’s stay or course of treatment in a
facility, the offices of a health care professional or other inpatient or outpatient health care setting,
including home care.
Covered Person - a policyholder, subscriber, enrollee or other individual participating in a health benefit
plan. A Covered Person includes a person who has applied for insurance and was declined or rescinded.
For purposes of these procedures, a reference to an Authorized Representative may also refer to a
Covered Person.
Emergency Medical Condition - a medical condition manifesting itself by acute symptoms of sufficient
severity, including severe pain, such that a prudent lay-person with an average knowledge of health and
medicine, acting reasonably, would have believed that the absence of immediate medical attention would
result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would
place the person’s health or, with respect to a pregnant woman, the health of the woman or her unborn
child, in serious jeopardy.
Emergency Services - with respect to an Emergency Medical Condition:
1.
A medical screening examination that is within the capability of the emergency department of a
Hospital, including ancillary services routinely available to the emergency department to evaluate
such Emergency Medical Condition; and
2.
Such further medical examination and treatment, to the extent they are within the capability of the
staff and facilities available at a hospital, to Stabilize a patient.
16AMD-IEX-CT
21
Final Adverse Determination - an Adverse Determination that has been upheld by Us at the completion of
Our internal Grievance process, or for which the internal Grievance process has been deemed
exhausted.
Grievance - a written complaint or, if the complaint involves an Urgent Care Request, an oral complaint,
submitted by a Covered Person regarding:
1.
The availability, delivery or quality of health care services, including a complaint regarding an
Adverse Determination made pursuant to Utilization Review;
2.
Claims payment, handling or reimbursement for health care services; or
3.
Any matter pertaining to the contractual relationship between a Covered Person and Us.
Medical Necessity - health care services that a Physician, exercising prudent clinical judgment, would
provide to a Covered Person for the purpose of preventing, evaluating, diagnosing or treating an Illness,
Injury, disease or its symptoms, and that are:
1.
In accordance with generally accepted standards of medical practice;
2.
Clinically appropriate, in terms of type, frequency, extent, site and duration and considered
effective for the Covered Person’s Illness, Injury or disease; and
3.
Not primarily for the convenience of the Covered Person, Physician or other health care provider
and not more costly than an alternative service or sequence of services at least as likely to produce
equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that Covered
Person’s Illness, Injury or disease.
Prospective Review - Utilization Review conducted prior to an admission or the provision of a health care
service or a course of treatment, in accordance with Our requirement that such service or treatment be
approved, in whole or in part, prior to such service’s or treatment’s provision.
Rescission - a retroactive cancellation or discontinuance of coverage under a health benefit plan based
upon the Covered Person performing an act or practice that constitutes fraud or makes intentional
misrepresentation of material fact. Rescission does not include a cancellation or discontinuance of
coverage under a health benefit plan if such cancellation or discontinuance has a prospective effect only,
or such cancellation or discontinuance is effective retroactively to the extent it is attributable to the
Covered Person’s failure to timely pay required premiums or contributions towards the cost of such
coverage.
Retrospective Review - any review of a request for a benefit that is not a Prospective Review or
Concurrent Review. Retrospective Review does not include a review of a request that is limited to the
veracity of documentation or the accuracy of coding.
Urgent Care Request - a request for a health care service or course of treatment:
1.
2.
For which the time period for making a non-Urgent Care Request determination:

Could seriously jeopardize the life or health of the Covered Person or the ability of the
Covered Person to regain maximum function; or

In the opinion of a health care professional with knowledge of the Covered Person’s medical
condition, would subject the Covered Person to severe pain that cannot be adequately
managed without the health care service or treatment being requested; or
For a substance use disorder, or for a co-occurring mental disorder, or for a mental disorder
requiring inpatient services, partial hospitalization, residential treatment, or intensive outpatient
services necessary to keep a Covered Person from requiring an inpatient setting.
An Urgent Care Request includes a Concurrent Review Urgent Care Request involving an admission,
availability of care, continued stay or health care service for a Covered Person who has received
Emergency Services but has not been discharged from the facility.
16AMD-IEX-CT
22
Utilization Review - the use of a set of formal techniques designed to monitor the use of, or evaluate the
Medical Necessity, appropriateness, efficacy or efficiency of, health care services, health care
procedures, or health care settings. Such techniques may include the monitoring of or evaluation of:
1.
Health care services performed or provided in an outpatient setting;
2.
The formal process of determining, prior to discharge from a facility, the coordination and
management of the care that a patient receives following discharge from a facility;
3.
Opportunities or requirements to obtain a clinical evaluation by a health care professional other
than the one originally making a recommendation for a proposed health care service;
4.
Coordinated sets of activities conducted for the individual patient management of serious,
complicated, protracted or other health conditions; or
5.
Prospective Review, Concurrent Review, Retrospective Review or certification.
5. Section 8: Defined Terms is modified by adding the following definition:
Surprise Bill - A bill for health care services, other than emergency services, received by an insured for
services rendered by an out-of-network health care provider, where such services were rendered by such
out-of-network provider at an in-network facility, during a service or procedure performed by an in-network
provider or during a service or procedure previously approved or authorized by the health carrier and the
insured did not knowingly elect to obtain such services from such out-of-network provider.
A "surprise bill" does not include a bill for health care services received by an insured when an in-network
health care provider was available to render such services and the insured knowingly elected to obtain
such services from another health care provider who was out-of-network.
6. Section 8: Defined Terms is modified by replacing definitions with the
following:
Autism Spectrum Disorders - means "autism spectrum disorder" as set forth in the most recent edition
of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.
Behavior Therapy - any interactive behavioral therapies derived from evidence-based research and
consistent with the services and interventions designated by the Connecticut Commissioner of
Developmental Services, including, but not limited to, applied behavior analysis, cognitive behavioral
therapy, or other therapies supported by empirical evidence of the effective treatment of individuals
diagnosed with Autism Spectrum Disorder, that are:

Provided to children less than twenty-one years of age; and

Provided or supervised by any of the following:

a behavior analyst who is certified by the Behavior Analyst Certification Board,

a licensed Physician, or

a licensed psychologist.
Behavioral Therapy is considered to be supervised by a behavior analyst, licensed Physician or licensed
psychologist when the supervision entails at least one hour of face-to-face supervision of the autism
spectrum disorder services provided for each ten hours of behavioral therapy provided by the supervised
provider.
16AMD-IEX-CT
23
7. Section 9: Outpatient Prescription Drug Coverage is modified by adding the
section Benefits for Oral Chemotherapeutic Agents:
Benefits for Oral Chemotherapeutic Agents
Oral chemotherapeutic agent Prescription Drug Products will be provided at a level no less favorable than
chemotherapeutic agents are provided under Pharmaceutical Products – Outpatient in your Certificate of
Coverage.
8. Section 9: Outpatient Prescription Drug Coverage is modified by replacing the
section for Coupons, Incentives and Other Communications with the following:
Coupons, Incentives and Other Communications:
At various times, we may send mailing or provide other communications to you, your Physician or your
pharmacy that communicate a variety of messages, including information about Prescription and nonprescription Drug Products. These communications may include offers that enable you, at your discretion,
to purchase the described product at a discount. Pharmaceutical manufacturers or other nonUnitedHealthcare entities may pay for and/or provide content for these communications and offers. Only
you and your Physician can determine whether a change in your Prescription and/or non-prescription
Drug regimen is appropriate for your medical condition.
following exclusion:
27. Dental products, including but not limited to prescription fluoride topicals. This exclusion does not
apply to Pediatric Dental Services. For coverage information on Pediatric Dental services, refer to Section
10: Pediatric Dental Services.
10. Section 9: Outpatient Prescription Drug Coverage is modified by replacing the
definitions for Brand-Name and Generic with the following:
Brand-Name- a Prescription Drug Product that (1) is manufactured and marketed under a trademark or
name by a specific drug manufacturer; or (2) that We identify as a Brand-Name Product, based on
available data resources including, but not limited to, data sources such as medi-span or First DataBank,
that classify drugs as either brand or generic based on a number of factors. You should know that all
products identified as a "brand name" by the manufacturer, pharmacy or your Physician may not be
classified as Brand-Name by Us.
Generic- a Prescription Drug Product that (1) is chemically equivalent to a Brand-Name drug; or (2) that
we identify as a Generic product based on available data resources including, but not limited to, data
sources such as medi-span or First DataBank, that classify drugs as either brand or generic based on a
number of factors.
16AMD-IEX-CT
24
following sub-section:
Section 4: Your Right to Request an Exclusion
Exception
When a Prescription Drug Product is excluded from coverage, you or your representative may request an
exception to gain access to the excluded Prescription Drug Product. To make a request, contact us in
writing or call the toll-free number on your ID card. We will notify you of our determination within 72
hours.
Urgent Requests
If your request requires immediate action and a delay could significantly increase the risk to your health,
or the ability to regain maximum function, call us as soon as possible. We will provide a written or
electronic determination within 24 hours.
External Review
If you are not satisfied with our determination of your exclusion exception request, you may be entitled to
request an external review. You or your representative may request an external review by sending a
written request to us to the address set out in the determination letter or by calling the toll-free number on
your ID card. The Independent Review Organization (IRO) will notify you of our determination within 72
hours.
Expedited External Review
If you are not satisfied with our determination of your exclusion exception request and it involves an
urgent situation, you or your representative may request an expedited external review by calling the tollfree number on your ID card or by sending a written request to the address set out in the determination
letter. The IRO will notify you of our determination within 24 hours.
Detailed information about the External and Expedited External Review processes can be found above
under "Section 6: Questions, Complaints and Appeals.
Effective Date of this Amendment: January 1, 2016
16AMD-IEX-CT
25

Connecticut - UnitedHealthcare

Transcription

Similar documents

to the Orthodontist - Guajardo Orthodontics

Patient Referral Benefit Support Form

HELP DENTAID TO END ORAL PAIN

Children in Need of Dental Treatment Program

to this!

Grace Dental 12425 55th St N Lake Elmo, MN 55042 phone 651

COMMUNICATING WITH THE DENTAL LABORATORY

ACDLA Cosmetic Dental Grant Campaign

SAVE 50%