Tekmark Global Solutions Employee Benefit Plan Summary of Plan

Transcription

Tekmark Global Solutions Employee Benefit Plan
Summary of Plan #503 Summary Plan Descriptions (SPD’s)
Effective April 1, 2013
Tekmark Global Solutions, LLC (“Employer”) has established the Tekmark Global
Solutions Employee Benefit Plan (“Plan”) for the benefit of eligible employees of
Employer and any affiliated companies participating in the Plan. The scope of benefit
options offered under the Plan are identified on Appendix A.
The Plan is established pursuant to a plan document, into which the insurance policies,
certificates of coverage, and/or Summary Plan Descriptions for each of the benefit
options are incorporated. You may request a copy of that plan document by contacting
that Plan Administrator identified herein.
The benefits provided by each of the benefit options are described in more detail in
certificates of coverage or “booklets” provided by the insurance carrier (if fully insured) or
summary plan descriptions provided by the employer (collectively, the certificates,
booklets and/or Summary Plan Descriptions are referred to as the “Benefit Option
Summaries”) attached to this document.
Nevertheless, if there is a conflict between the language in this Summary and the Benefit
Option Summaries, the Benefit Option Summaries will control. If there is a conflict
between the Benefit Option Summaries and the Plan Document, the Plan Document
controls.
If you have any questions, contact the plan administrator identified below.
General Plan Information
Plan Name
Tekmark Global Solutions Employee Benefit Plan
Plan Sponsor
Tekmark Global Solutions, LLC
Plan Number
501
Employer I.D.
22-3532457
The Plan is a welfare benefit plan as defined in
ERISA Section 3(1). Some of the benefit
options offered through the Plan are provided
Type of Plan/Administration
pursuant to an insurance contract issued to the
Employer by an insurance carrier. Others are
self-insured and are paid from the employer’s
general assets.
Plan Year
April 1st to March 31st
Plan Administrator
The Plan Administrator will make determinations that may
be required from time to time in the administration of the
Program. The Plan Administrator will have the sole
authority, discretion and responsibility to interpret and apply
the terms of the Plan and to determine all factual and legal
questions under the Plan except as otherwise specifically
delegated to a third party, such as insurance carrier (see
below for the insurance carrier’s authority under a fully
insured plan). The Plan Administrator or its designee may
100 Metroplex Drive, Suite 102
Edison, NJ 08817
732-572-5400
adopt such rules as it deems necessary, desirable, or
appropriate. All determinations, interpretations, rules, and
decisions of the Plan Administrator or its designee shall be
made in its sole discretion and shall be conclusive and
binding upon all persons having or claiming to have any
interest or right under the Program.
If a benefit option is fully insured, the insurance carrier will
have the sole authority and discretion to interpret and
construe the Program and to determine all factual and legal
questions under the Program with respect to all initial
claims and appeals for benefits. This delegated authority
includes, but is not limited to, determinations of entitlement
to benefits and the amounts of the benefits to be paid.
Benefit Design Specialists, Inc.
600 Wilson Lane, Suite 200
Mechanicsburg, PA 17055
717-766-8844
717-766-8844
717-766-8844
Charles Miller, III, CFO
100 Metroplex Drive, Suite 102
Edison, NJ 08817
732-572-5400
MERP/HRA Plan Service Provider
Cafeteria Plan Service Provider
COBRA Plan Service Provider
Agent for Services of Legal Process
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Appendix A
Tekmark Global Solutions
Employee Benefit Plan
As of April 1, 2013
Medical
Option
Funding
Plan Type
Claims Administrator
$2,500
Deductible POS
Fully Insured
POS Medical
United Healthcare
866-633-2446
www.myuhc.com
$2,500
Deductible HSA
Fully Insured- MERP option
POS HSA Medical
United Healthcare
866-633-2446
www.myuhc.com
Dental
Option
Base Dental
Funding
Self Insured Guardian
administrated
Plan Type
Base Dental
Guardian
888-600-1600
www.guardiananytime.com
Voluntary Life & Voluntary Long Term Disability
Option
Vol Life & LTD
Funding
Fully Insured through Guardian
Plan Type
Life & LTD
Guardian
888-600-1600
www.guardiananytime.com
CAFETERIA PLAN
PREMIUM REDUCTION OPTION PLUS
FLEXIBLE SPENDING ACCOUNTS PLUS
HEALTH SAVINGS ACCOUNTS
SUMMARY PLAN DESCRIPTION
AS ADOPTED BY
TEKMARK GLOBAL SOLUTIONS, LLC
AMENDED & RESTATED
APRIL 1, 2012
TABLE OF CONTENTS
PART 1. INTRODUCTION.............................................................................................................................................. 3
PART 2. GENERAL INFORMATION ABOUT THE PLAN ................................................................................................. 3
Q-1
What is the purpose of the Plan? ...........................................................................................3
Q-2
What benefits are offered through the Plan? .........................................................................3
Q-3
Who can participate in the Plan? ...........................................................................................3
Q-4
What happens if I terminate employment (or cease to be eligible) and then am
rehired (become eligible again) during the same Plan Year? ................................................3
Q-5
What happens if I take a leave of absence? ...........................................................................4
Q-6
What tax advantages can I gain by participating in the Plan? ...............................................4
Q-7
How do I become a Participant? ...........................................................................................5
Q-8
What are the enrollment periods? .........................................................................................5
Q-9
How long is my election to participate (or not to participate) effective? ..............................6
Q-10 What happens if I fail to return my Benefit Election Form? .................................................6
Q-11 Can I change my election during the Plan Year? ..................................................................6
Q-12 How are my Benefit Package Options that I elect paid for under this Plan?.........................9
Q-13 What happens if a claim for benefits under the Plan is denied? ............................................9
Q-14 What effect will Plan participation have on Social Security and other benefits? ................10
PART 3. CASH BENEFITS ........................................................................................................................................... 10
PART 4. HEALTH FSA BENEFITS .............................................................................................................................. 10
Q-1
Who can participate in the Health FSA? .............................................................................10
Q-2
How do I become a Participant? .........................................................................................10
Q-3
When does coverage under the Health FSA end? ...............................................................10
Q-4
What happens if I take a leave of absence? .........................................................................11
Q-5
What happens if I fail to return my Benefit Election Form? ...............................................11
Q-6
How is my annual election amount credited to my Health FSA? .......................................11
Q-7
What annual benefits are available under the Health FSA, and how much will
they cost? ............................................................................................................................11
Q-8
How do I submit a claim for reimbursement under the Health FSA? .................................11
Q-9
What is an “Eligible Medical Expense”? ............................................................................12
Q-10 How do I receive my payment under the Health FSA? .......................................................13
Q-11 Who is an “eligible dependent” for which I can claim expenses for
reimbursement? ...................................................................................................................13
Q-12 When must a reimbursable expense be incurred? ...............................................................13
Q-13 Can I change the election during the year? .........................................................................13
Q-14 What happens if I still have a balance in my Account at the end of the Plan Year? ...........13
Q-15 Can I continue coverage in my Account? ...........................................................................13
Q-16 What happens if a claim for benefits under the Health FSA is denied? ..............................15
Q-17 Will my health information be kept confidential?...............................................................16
PART 5. DEPENDENT CARE ASSISTANCE BENEFIT .................................................................................................. 16
Q-1
Who can participate in a DCAP? ........................................................................................16
Q-2
How do I become a Participant? .........................................................................................16
Q-3
When does coverage under the DCAP end? .......................................................................16
Q-4
What happens if I take a leave of absence? .........................................................................16
Q-5
What happens if I fail to return my Benefit Election form? ................................................16
Q-6
How is my annual election amount credited to my DCAP Account? .................................16
Q-7
Are there any other limits on what DCAP benefits are tax free? ........................................16
Q-8
Is there any other way I can save taxes on my DCAP expenses? .......................................17
Q-9
What is the Household and Dependent Care Credit? ..........................................................17
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SPD (REV. 11/2010)
Q-10
Q-11
Q-12
Q-13
Q-14
Q-15
Q-16
Q-17
Q-18
Amended: April 1, 2012
If I participate in the DCAP, can I claim the Household and Dependent Care
Credit on my federal income tax return? .............................................................................17
Under what circumstances can I receive reimbursement under the DCAP”? .....................17
How do I submit a claim for reimbursement under the DCAP? .........................................18
Will I be taxed on the DCAP benefits I receive? ................................................................18
Can I change my election if I change day care providers during the year and the
rates are different? ...............................................................................................................19
Can I change my election if a relative starts keeping my children for free? .......................19
What happens if I still have a balance in my DCAP Account at the end of the Plan
Year? ...................................................................................................................................19
What happens if my claim for DCAP benefits is denied? ...................................................19
How do I receive my payment under the DCAP? ...............................................................20
PART 6. HEALTH SAVINGS ACCOUNT CONTRIBUTIONS .......................................................................................... 20
Q-1
What is a Health Savings Account for which contributions can be made under this
Plan?....................................................................................................................................20
Q-2
Who is eligible for an HSA? ...............................................................................................20
Q-3
Who is an Account Beneficiary? .........................................................................................20
Q-4
Who is a Custodian or Trustee? ..........................................................................................20
Q-5
What are the rules regarding contributions made to an HSA under the Plan? ....................20
Q-6
What are the election change rules under this Plan for HSA elections? .............................21
Q-7
Where Can I get More Information on My HSA and its Related Tax
Consequences? ....................................................................................................................21
PART 7. MYSOURCECARD®...................................................................................................................................... 21
PART 8. ERISA RIGHTS ........................................................................................................................................... 23
PART 9. PLAN INFORMATION SUMMARY ................................................................................................................. 25
1. Employer Organization ..............................................................................................................25
2. Plan Elections .............................................................................................................................25
3. Eligibility Requirements.............................................................................................................25
4. Plan Entry Date ..........................................................................................................................26
5. Benefit Package Options ............................................................................................................26
6. Flexible Spending Account Elections.........................................................................................26
7. Incorporated By Reference .........................................................................................................27
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PAGE II
SPD (REV. 11/2010)
Section 125 Cafeteria Plan
Part 1. Introduction
Your employer (“Employer”) is pleased to sponsor an employee benefit program known as a Cafeteria Plan (“Plan”) for
certain Eligible Employees of the Employer. It is called a Cafeteria Plan because you can choose from a selection of different
insurance and fringe benefit programs according to your needs. Your Employer gives you this opportunity to use a salary
conversion arrangement through which you can use pre-tax dollars to pay for your benefits instead of paying for the benefits
through after-tax payroll deductions. By paying for the benefits with pre-tax dollars, you save money by not having to pay
Social Security and income taxes on your salary reduction. However, you may still have the option of paying for your
benefits with after-tax dollars.
This Summary Plan Description (“SPD”) describes the basic features of the Plan; how it operates, and how you can get the
maximum advantage from it. The Plan is established pursuant to a plan document into which this SPD is incorporated (i.e.
the plan document and this SPD constitute the plan document). However, if a conflict exists between the plan document and
this SPD, the plan document will take precedence.
Part 2. General Information about the Plan
Q-1
What is the purpose of the Plan?
This Plan is designed to allow Eligible Employees to choose one or more of the benefits offered through the Plan and,
using funds provided through employee salary reduction, to pay for the selected benefits with pre-tax dollars. It is
established for the exclusive benefit of Participants.
Q-2
What benefits are offered through the Plan?
The Plan allows you to make your share of the contributions with Pre-tax contributions for qualified benefits (“Benefit
Package Options”) offered under the Plan to the extent such benefits are listed in Part 9 below. Benefit Package Options
offered under the Plan may include but are not limited to group benefits accident and health benefits sponsored by your
employer, individual accident and health insurance policies issued to employees (to the extent approved by the
Employer), a Health and/or Dependent Care FSA, and/or a Code Section 223 Health Savings Account.
You will receive information materials before each enrollment period explaining the various benefit options your
Employer is offering for the next Plan Year.
Q-3
Who can participate in the Plan?
Any employee (as that term is defined in the Plan Document) of the Employer who satisfies the Eligibility Requirements
established by the Employer in the Plan Information Summary (as summarized in Part 9 below) is eligible to participate
in this Plan.
You will cease to be a Participant if:
the Plan terminates,
You cease to be eligible for the Plan (e.g. the Participant’s employment is terminated),
You revoke your election to participate, or
the Plan is amended to exclude you or the class of employees of which you are a member.
You may be entitled to temporarily continue coverage under one or more of the Benefit Package Options that provide
group health coverage. Refer to the applicable plan summaries for more information on COBRA continuation coverage.
Q-4
What happens if I terminate employment (or cease to be eligible) and then am rehired (become
eligible again) during the same Plan Year?
If you terminate your employment or you cease to be eligible for any reason, including (but not limited to) disability,
retirement, layoff or voluntary resignation, and then you are rehired or again become eligible within 30 days or less of
the date of a termination of employment or cessation of eligibility, then you will be reinstated in the Plan (assuming you
otherwise satisfy the eligibility requirements of the Plan) with the same elections you had before termination (subject to
any restrictions imposed under the applicable Benefit Package Options). If you are rehired or again become eligible more
than 30 days following termination of employment or cessation of eligibility and you are otherwise eligible to participate
in the Plan, then you may make new elections.
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SPD (REV. 11/2010)
Q-5
What happens if I take a leave of absence?
(a)
If you go on a qualifying unpaid leave under the Family and Medical Leave Act of 1993 (FMLA), to the extent
required by the FMLA, the Employer will continue to maintain your group health coverage on the same terms
and conditions as though you were still active (e.g., the Employer will continue to pay its share of the
contribution to the extent you opt to continue coverage).
(b) Your Employer may elect to continue all coverage for Participants while they are on paid leave (provided
Participants on non-FMLA paid leave are required to continue coverage). If so, you will pay your share of the
contributions by the method normally used during any paid leave (for example, with Pre-tax Contributions if
that is what was used before the FMLA leave began).
(c)
In the event of unpaid FMLA leave (or paid leave where coverage is not required to be continued), if you opt
to continue your group health coverage, you may pay your share of the contribution with after-tax dollars while
on leave, or you may be given the option to pre-pay all or a portion of your share of the contribution for the
expected duration of the leave with Pre-tax Contributions from your pre-leave compensation by making a
special election to that effect before the date such compensation would normally be made available to you
provided, however, that pre-payments of Pre-tax Contributions may not be utilized to fund coverage during the
next Plan Year, or by other arrangements agreed upon between you and the Plan Administrator (for example,
the Plan Administrator may fund coverage during the leave and withhold amounts from your compensation
upon your return from leave). The payment options provided by the Employer will be established in
accordance with Code Section 125, FMLA, and the Employer’s internal policies and procedures regarding
leaves of absence. Alternatively, the Employer may require all Participants to continue coverage during the
leave. If so, you may elect to discontinue your share of the required contributions until you return from leave.
Upon return from leave, you will be required to repay the contribution not paid during the leave in a manner
agreed upon with the Administrator.
(d) If your coverage ceases while on FMLA leave (e.g., for non-payment of required contributions), you will be
permitted to re-enter the Plan upon return from such leave on the same basis as you were participating in the
Plan prior to the leave, or as otherwise required by the FMLA. Your coverage under the Benefit Package
Options providing health coverage may be automatically reinstated provided that coverage for Employees on
non-FMLA leave is automatically reinstated upon return from leave.
Q-6
(e)
The Employer may, on a uniform and consistent basis, continue your group health coverage for the duration of
the leave following your failure to pay the required contribution. Upon return from leave, you will be required
to repay the contribution in a manner agreed upon by you and your Employer.
(f)
If you are commencing or returning from unpaid FMLA leave, your election under this Plan for Benefit
Package Options providing non-health benefits shall be treated in the same manner that elections for nonhealth Benefit Package Options are treated with respect to Participants commencing and returning from unpaid
non-FMLA leave.
(g)
If you go on an unpaid non-FMLA leave of absence (e.g., personal leave, sick leave, etc.) that does not affect
eligibility in this Plan or a Benefit Package Option offered under this plan, then you will continue to participate
and the contribution due will be paid by pre-payment before going on leave, by after-tax contributions while on
leave, or with catch-up contributions after the leave ends, as may be determined by the Administrator. If you
go on an unpaid leave that affects eligibility under this Plan or a Benefit Package Option, the election change
rules in Part 2 Q-11 below will apply. The Plan Administrator will have discretion to determine whether taking
an unpaid non-FMLA leave of absence affects eligibility.
What tax advantages can I gain by participating in the Plan?
By participating in the Plan, you will not have to pay income tax or Social Security tax on your elections. Following is
an illustration of how a hypothetical employee saved on taxes by participating in a cafeteria plan. Let’s assume our
hypothetical employee makes $2,500 each month and has 28% withheld for federal withholding and 7.65% for Social
Security. The employee’s take-home pay before participating in the Plan is $1,609 a month. Out of that, $348 a month is
paid for insurance benefits, $100 for Health FSA, and $200 for Dependent Care FSA. The employee decides to
participate in the cafeteria plan. By participating in the Plan and paying contributions on a pre-tax basis under the Plan,
the employee saved $230 a month. Following is a table to better illustrate the example.
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PAGE 4
SPD (REV. 11/2010)
Breakdown of Pay Check
and Deductions
Gross Monthly Pay
Not Participating
in Cafeteria Plan
Participating in
Cafeteria Plan
$2,500.00
$2,500.00
Less Premium for Major Medical
(348.00)
Less Medical/Dental Expenses
(100.00)
Less Day Care Expenses
(200.00)
Taxable Income
2,500.00
1,852.00
(700.00)
(519.00)
Less 7.65% Social Security Tax
(191.00)
(142.00)
Less Premium for Major Medical
(348.00)
Less 28% Federal Withholding
Less Health FSA Expenses
(100.00)
Less Day Care Expenses
(200.00)
Spendable Income
$961.00
$1,191.00
The employee saved $230 a month or $2,760 a year by participating in Plan!
This savings result in extra disposable income and this occurs because the employee participated in the Plan and made
the required employee contributions before the taxes were withheld. This is just one example of the possible tax savings
under the Plan.
Q-7
How do I become a Participant?
You become a Participant in the Cafeteria Plan by completing and submitting a Benefit Election Form (or Salary
Reduction Agreement) to the Plan Administrator (or its designee identified on the election form) during one of the
applicable enrollment periods described in Q-8 below. Your effective date of participation in the Cafeteria Plan is also
described in Q-8 below. Enrollment in the Cafeteria Plan does not necessarily result in enrollment in the Benefit Package
Options. Coverage under the Benefit Package Options that you elect will begin only as set forth in the summary plan
descriptions or other written material for each Benefit Package Option that you elect.
Q-8
What are the enrollment periods?
There are four enrollment periods:
1.
Enrollment Period prior to the Effective Date. This is the enrollment period that occurs before the Plan'
s
Effective Date (as described in the Adoption Agreement). An Election made during this Enrollment Period is
effective on the Effective Date of the Plan.
2.
Initial Enrollment Period. The Initial Enrollment Period is the period during which newly Eligible Employees
enroll in the Plan. The Initial Enrollment Period is described in the enrollment material provided by the Plan
Administrator. An election to participate that is made during this enrollment period will be effective on the Plan
Entry Date.
3.
Annual Enrollment Period. The Annual Enrollment Period is the period each year in which participants may
elect to change and/or continue their elections or Eligible Employees may elect to participate for the next Plan
Year. The Annual Enrollment Period is described in your enrollment material that you will receive prior to the
Annual Enrollment Period. An election to participate made during this period will be effective on the
anniversary date.
Effective April 1, 2009, eligible employees and participants will have a “Special Enrollment Right” under the
Flexible Benefits Plan that allows certain eligible but un-enrolled employees and Participants to enroll in a
Benefit Plan Option that is group health plan if the dependent child or employee: (1) loses coverage under a
Medicaid Plan under Title XIX of the Social Security Act; (2) loses coverage under State Children’s Health
Insurance Program (SCHIP) under Title XXI of the Social Security Act; or (3) becomes eligible for group
4.
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SPD (REV. 11/2010)
health plan premium assistance under Medicaid or SCHIP. The eligible employee or participant must request
an election change to enroll in group health plan coverage within 60 days from the date (1) the coverage
terminates under the Medicaid or SCHIP plan or (2) the employee or dependent child is determined eligible for
state premium assistance.
If you believe you are eligible for a Special Enrollment, you must contact the Administrator to request an election form
as soon as possible. A request for enrollment must be made in writing on the form provided by the Administrator. A
request for a Special Enrollment right must be made within 60 days of an event described above that occurs on or after
April 1, 2009.
If you have the ability to enroll by phone or Internet, separate enrollment periods may be established for paper,
telephone, and Internet. Your Employer will tell you what enrollment periods are established for each.
See Q-10 below for what happens when you fail to return a Benefit Election Form during the enrollment period.
Q-9
How long is my election to participate (or not to participate) effective?
Your elections (either to participate or not) are for the entire Plan Year, which is usually 12 months. The first Plan Year
and the last Plan Year may be for a shorter period. See Part 9 below for the exact dates of your Plan Year.
Q-10
What happens if I fail to return my Benefit Election Form?
If you are not currently participating in the Plan and you fail to return a Benefit Election Form before the end of the
applicable Enrollment Period, it will be assumed that you have elected to receive your full compensation in cash and you
cannot elect to become a Participant until the next Annual Enrollment Period or following the date you experience a
change in status that allows you to enroll mid Plan Year (assuming you timely change your election). If you are currently
participating in the Plan and fail to submit a Benefit Election Form by the end of the Annual Enrollment Period for the
next Plan Year, your elections for the next Plan Year will depend on which benefits you currently have.
If you have currently elected to pay for one of your Benefit Package Options (other than Health FSA, Code Section 223
Health Savings Account (HSA) and/or Dependent Care FSA) with pre-tax contributions, it will be assumed that you
want to continue these elections for the next Plan Year (and contribute your share of the cost on a pre-tax basis, adjusted
to reflect any increase in the contribution). Otherwise, your election under the Plan will terminate at the end of the Plan
Year.
Q-11
Can I change my election during the Plan Year?
Generally, you cannot change your election to participate in the Plan or vary the benefits you have selected during the
Plan Year, although your election will automatically terminate if you are no longer working for the Employer or you are
no longer eligible. You may change your elections only during the Annual Enrollment Period, and then the change will
not be effective until the beginning of the next Plan Year.
There are several important exceptions to this general rule. You may change or revoke your previous elections during the
Plan Year if you experience one of the events listed below.
Please refer to the Change of Status Matrix (distributed with this SPD) for a table of the qualifying events,
the benefits affected by each event, and the possible changes in elections that may take place for each
benefit. If you have a qualifying event, you must submit an Employee Statement of Qualifying Event form
(stating the event) and a Personal Benefit Election Change Request Form (stating the changes in elections)
within 30 days of the event to enroll.
Note: These rules do not apply to a Code Section 223 Health Savings Account offered under the Cafeteria Plan. See Part
6 below for more information regarding election changes related to the Health Savings Account.
1. Changes in Status. If one or more of the following Changes in Status occur, you may revoke your old election and
make a new election, provided that both the revocation and new election are on account of and correspond with the
Change in Status (as described below). Those occurrences which qualify as a Change in Status include the events
described below, as well as any other events which the Plan Administrator determines are permitted under subsequent
IRS regulations:
POP PLUS FSAS
•
Change in your legal marital status (such as marriage, legal separation, annulment,
divorce, or death of your Spouse),
•
Change in the number of your tax Dependents (such as the birth of a child, adoption or
placement for adoption of a Dependent, or death of a Dependent),
PAGE 6
SPD (REV. 11/2010)
•
Any of the following events that change the employment status of you, your Spouse, or
your Dependent that affect benefit eligibility under a cafeteria plan (including this
Plan) or other employee benefit plan of yours, your Spouse, or your Dependents. Such
events include any of the following changes in employment status: termination or
commencement of employment, a strike or lockout, a commencement of or return from
an unpaid leave of absence, a change in worksite, switching from salaried to hourlypaid, union to non-union, or part-time to full-time; incurring a reduction or increase in
hours of employment; or any other similar change which makes the individual become
(or cease to be) eligible for a particular employee benefit,
•
Event that causes your Dependent to satisfy or cease to satisfy an eligibility
requirement for a particular benefit (such as attaining a specified age, getting married,
or ceasing to be a student), or
•
Change in your, your Spouse’s, or your Dependent’s place of residence.
If a Change in Status occurs, you must inform the Plan Administrator and complete a new election for Pre-Tax
Contributions within 30 days of the occurrence.
If you wish to change your election based on a Change in Status, you must establish that the revocation is on
account of and corresponds with the Change in Status. The Plan Administrator (in its sole discretion) shall
determine whether a requested change is on account of and corresponds with a Change in Status. As a general
rule, a desired election change will be found to be consistent with a Change in Status event if the event affects
coverage eligibility (for the Dependent Care FSA, the event may also affect eligibility for the dependent care
exclusion). A Change in Status affects coverage eligibility if it results in an increase or decrease in the number
of dependents who may benefit under the plan.
In addition, you must also satisfy the following specific requirements in order to alter your election based on that
Change in Status:
•
Loss of Dependent Eligibility. For accident and health benefits (e.g., health, dental and
vision coverage, accidental death and dismemberment coverage, and Health FSA
benefits), a special rule governs which type of election change is consistent with the
Change in Status. For a Change in Status involving your divorce, annulment, or legal
separation from your Spouse; the death of your Spouse or your Dependent; or your
Dependent ceasing to satisfy the eligibility requirements for coverage, your election to
cancel accident or health benefits for any individual other than your Spouse involved in
the divorce, annulment, or legal separation, your deceased Spouse or Dependent, or
your Dependent that ceased to satisfy the eligibility requirements, would fail to
correspond with that Change in Status. Hence, you may only cancel accident or health
coverage for the affected Spouse or Dependent.
Example: Employee Mike is married to Sharon, and they have one child. The employer offers a calendar
year cafeteria plan that allows employees to elect no health coverage, employee-only coverage, employee-plus-onedependent coverage, or family coverage. Before the plan year, Mike elects family coverage for himself, his wife
Sharon, and their child. Mike and Sharon subsequently divorce during the plan year; Sharon loses eligibility for
coverage under the plan, while the child is still eligible for coverage under the plan. Mike now wishes to cancel his
previous election and elect no health coverage. The divorce between Mike and Sharon constitutes a Change in
Status. An election to cancel coverage for Sharon is consistent with this Change in Status. However, an election to
cancel coverage for Mike and/or the child is not consistent with this Change in Status. In contrast, an election to
change to employee-plus-one-dependent coverage would be consistent with this Change in Status.
POP PLUS FSAS
•
However, you may increase your election to pay for COBRA coverage under the
Employer’s plan for yourself (if you still have pay) or any other individual who lost
coverage but is a still a tax dependent (e.g. a child who lives with you and to whom
you provide over half of their support but who has lost eligibility under the Plan).
•
Gain of Coverage Eligibility under Another Employer’s Plan. For a Change in Status
in which you, your Spouse, or your Dependent gain eligibility for coverage under
another employer’s cafeteria plan (or qualified benefit plan) as a result of a change in
your marital status or a change in your, your Spouse’s, or your Dependent’s
employment status, your election to cease or decrease coverage for that individual
PAGE 7
SPD (REV. 11/2010)
under the Plan would correspond with that Change in Status only if coverage for that
individual becomes effective or is increased under the other employer’s plan.
•
Dependent Care FSA Benefits. With respect to the Dependent Care FSA benefit (when
offered by the Plan), you may change or terminate your election only if (1) such change
or termination is made on account of and corresponds with a Change in Status that
affects eligibility for coverage under the Plan; or (2) your election change is on account
of and corresponds with a Change in Status that affects the eligibility of dependent care
assistance expenses for the available tax exclusion.
Example: Employee Mike is married to Sharon, and they have a 12-year-old daughter. The employer’s plan
offers a dependent care expense reimbursement program as part of its cafeteria plan. Mike elects to reduce his salary
by $2,000 during a plan year to fund dependent care coverage for his daughter. In the middle of the plan year when
the daughter turns 13 years old, however, she is no longer eligible to participate in the dependent care program. This
event constitutes a Change in Status. Mike’s election to cancel coverage under the dependent care program would be
consistent with this Change in Status.
•
Group Term Life Insurance, Disability Income, or Dismemberment Benefits. In the
case of group term life insurance or disability income and dismemberment benefits, if
you experience any Change in Status (as described above), you may elect to either
increase or decrease coverage.
Example: Employee Mike is married to Sharon and they have one child. The employer’s plan offers a
cafeteria plan which funds group-term life insurance coverage (and other benefits) through salary reduction. Before
the plan year Mike elects $10,000 of group-term life insurance. Mike and Sharon subsequently divorce during the
plan year. The divorce constitutes a Change in Status. An election by Mike either to increase or to decrease his
group-term life insurance coverage would each be consistent with this Change in Status.
2. Special Enrollment Rights. If you, your Spouse and/or a Dependent are entitled to special enrollment rights under a
group health plan, you may change your election to correspond with the special enrollment right. Thus, for example, if
you declined enrollment in medical coverage for yourself or your eligible Dependents because of outside medical
coverage and eligibility for such coverage is subsequently lost due to certain reasons (such as legal separation, divorce,
death, termination of employment, reduction in hours, or exhaustion of COBRA period), you may be able to elect
medical coverage under the Plan for yourself and your eligible Dependents who lost such coverage. Furthermore, if you
have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may also be able to enroll
yourself, your Spouse, and your newly acquired Dependents, provided that you request enrollment within 30 days after
the marriage, birth, adoption, or placement for adoption. An election change that corresponds with a special enrollment
must be prospective, unless the special enrollment is attributable to the birth, adoption, or placement for adoption of a
child, which may be retroactive up to 30 days back to the date of the birth, adoption, or placement for adoption. Please
refer to the group health plan description for an explanation of special enrollment rights.
3. Certain Judgments, Decrees, and Orders. If a judgment, decree, or order from a divorce, separation, annulment, or
custody change requires your Dependent child (including a foster child who is your tax Dependent) to be covered under
this Plan, you may change your election to provide coverage for the Dependent child. If the order requires that another
individual (such as your former Spouse) cover the Dependent child, and such coverage is actually provided, you may
change your election to revoke coverage for the Dependent child.
4. Entitlement to Medicare or Medicaid. If you, your Spouse, or a Dependent becomes entitled to Medicare or
Medicaid, you may cancel that person’s accident or health coverage. Similarly, if you, your Spouse, or a Dependent who
has been entitled to Medicare or Medicaid loses eligibility for such, you may, subject to the terms of the underlying plan,
elect to begin or increase that person’s accident or health coverage.
5. Change in Cost. If the Plan Administrator notifies you that the cost of your coverage under the Plan significantly
increases or decreases during the Plan Year, regardless of whether the cost change results from action by you (such as
switching from full-time to part-time) or the Employer (such as reducing the amount of Employer contributions for a
certain class of employees), you may make certain election changes. If the cost significantly increases, you may choose
either (a) to make an increase in your contributions, (b) revoke your election and receive coverage under another Benefit
Package Option which provides similar coverage, or (c) drop coverage altogether if no similar coverage exists. If the cost
significantly decreases, you may revoke your election and elect to receive coverage provided under the option that
decreased in cost. For insignificant increases or decreases in the cost of Benefit Package Options, however, the Plan
Administrator will automatically adjust your election contributions to reflect the minor change in cost. The Plan
POP PLUS FSAS
PAGE 8
SPD (REV. 11/2010)
Administrator (in its sole discretion) will determine whether the requirements of this Part are met. The Change in Cost
provisions do not apply to Health FSA benefits.
Example: Employee Mike is covered under an indemnity option of his employer’s accident and health insurance
coverage. If the cost of this option significantly increases during a period of coverage, the Employee may make a
corresponding increase in his payments or may instead revoke his election and elect coverage under an HMO option.
6. Change in Coverage. If the Plan Administrator notifies you that your coverage under the Plan is significantly
curtailed you may revoke your election and elect coverage under another Benefit Package Option which provides similar
coverage. If the significant curtailment amounts to a complete loss of coverage, you may also drop coverage if no other
similar coverage is available. Further, if the Plan adds or significantly improves a benefit option during the Plan Year,
you may revoke your election and elect to receive on a prospective basis coverage provided by the newly-added or
significantly improved option, so long as the newly added or significantly improved option provides similar coverage.
Also, you may make an election change that is on account of and corresponds with a change made under another
employer plan (including a plan of the Employer or another employer), so long as: (a) the other employer plan permits
its participants to make an election change permitted under the IRS regulations; or (b) this Plan permits you to make an
election for a period of coverage which is different from the period of coverage under the other employer plan. Finally,
you may change your election to add coverage under this Plan for yourself, your Spouse, or your Dependent if such
individual(s) loses coverage under any group health coverage sponsored by a governmental or educational institution.
The Plan Administrator (in its sole discretion) will determine whether the requirements of this Part are satisfied. The
Change in Coverage provisions do not apply to Health FSA benefits.
With the exception of special enrollment resulting from birth, placement for adoption or adoption, all election changes
are prospectively effective from the date of the election or such later time as determined by the Plan Administrator.
Additionally, the Plan’s Administrator may modify your election(s) downward during the Plan Year if you are a Key
Employee or Highly Compensated Individual (as defined by the Internal Revenue Code), if necessary to prevent the Plan
from becoming discriminatory within the meaning of the federal income tax law.
Q-12
How are my Benefit Package Options that I elect paid for under this Plan?
You may be required to pay for any Benefit Package Option coverage that you elect with Pre-tax Contributions.
Alternatively, the Employer may allow you to pay your share of the contributions with after-tax contributions. The
enrollment material you receive will indicate whether you have to pay with Pre-Tax Contributions or whether you have
an option to choose to pay with after-tax contributions.
When you elect to participate both in this Cafeteria Plan, an amount equal to your share of the annual cost of those
Benefit Package Options that you choose divided by the applicable number of pay periods you have during that Plan
Year is deducted from each paycheck after your election date. If you have chosen to use Pre-tax Contributions (or it is a
plan requirement), the deduction is made before any applicable federal and/or state taxes are withheld.
The Employer may provide you with employer contributions over which you have discretion to choose how to apply to
the various Benefit Package Options available under the Cafeteria Plan.
Q-13
What happens if a claim for benefits under the Plan is denied?
If you are denied a benefit under this Plan (e.g. election changes, eligibility for pre-tax benefits), you should proceed in
accordance with the following claims review procedures. If you are denied a benefit under one of the Benefit Package
Options, you should proceed in accordance with the claims review procedures established for that particular Benefit
Package Option, if any.
Step 1:
Notice is received from Plan Service Provider. If your claim is denied, you will receive written notice from
the Plan Service Provider that your claim is denied as soon as reasonably possible but no later than 30 days after receipt
of the claim. The Plan Service Provider may take up to an additional 15 days to review your claim. You will be provided
written notice of the need for additional time prior to the end of the 30-day period.
Step 2:
Review your notice carefully. Once you have received your notice from the Plan Service Provider, review
it carefully. The notice will contain:
The reason(s) for the denial and the Plan provisions on which the denial is based;
A description of any additional information necessary for you to perfect your claim, why the information is necessary,
and your time limit for submitting the information;
A description of the Plan’s appeal procedures and the time limits applicable to such procedures;
A right to request all documentation relevant to your claim.
POP PLUS FSAS
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SPD (REV. 11/2010)
Step 3:
If you disagree with the decision, you may file an appeal. If you do not agree with the decision, and you
wish to appeal, you must file a written appeal in accordance with the Notice referenced in Step 1 no later than 180 days
of receipt of that Notice. You should submit all information identified in the notice of denial as necessary to perfect your
claim and any additional information that you believe would support your claim.
Step 4:
Notice of Denial following appeal. If the claim is again denied, you will be notified in writing. If there is
only one level of appeal, notice of the denial will be sent no later than 60 days after the appeal is received. See below for
more information if the Plan has established two levels of appeal.
Step 5:
Review your notice carefully. You should take the same action that you took in Step 2 described above.
The notice will contain the same type of information that is provided in the first notice of denial.
Step 6 (if there is a second level of appeal as indicated in the notice of denial referenced in Step One and/or Four above):
If you still disagree with the decision, and you wish to appeal, you must file a second level appeal with the Plan
Administrator within the time allotted for appealing as set forth in the notice of denial from the Plan Service Provider
(referenced in Step 4). You should gather any additional information that is identified in the notice as necessary to
perfect your claim and any other information that you believe will support your claim.
If the Plan Administrator denies your second level appeal, you will receive notice within 30 days after the Plan
Administrator receives your claim. The notice will contain the same type of information that was referenced in Step 2
above.
Q-14
What effect will Plan participation have on Social Security and other benefits?
Plan participation will reduce the amount of your taxable compensation. Accordingly, there could be a decrease in your
Social Security benefits and/or other benefits (e.g., pension, disability and life insurance) that are based on taxable
compensation.
Part 3. Cash Benefits
During any one Plan Year, the Maximum Contribution Amount total a Participant can elect cannot exceed the sum of the
maximum contributions for Benefit Package Options offered under Part 9 below. Any part of this annual benefit limit
you do not apply toward tax-free benefits (or the remainder of your annual pay if less than the unused portion of the
Maximum Contribution Amount) will be paid to you as regular, taxable compensation.
Part 4. Health FSA Benefits
Participation in the Medical Reimbursement Plan (Health FSA), if listed as a benefit offered under the Plan (see Part 9
below), allows you to purchase a specific level of Health FSA benefits, paying for coverage with pre-tax dollars elected
on the Benefit Election Form in lieu of a corresponding amount of current pay. This arrangement helps you because the
level of coverage you elect is nontaxable, and you save Social Security and income taxes on the amount of premiums
you pay.
Q-1
Who can participate in the Health FSA?
If you are eligible to be a participant in the Cafeteria Plan, you are eligible to participate in the Health FSA.
Q-2
You can participate by electing the Health FSA during the applicable Enrollment Periods described in Part 2, Q-8 to
determine when your participation will begin. Effective date of participation will vary by Enrollment Period. Once you
elect benefits under a Health FSA, a Health Care Account will be set up in your name to record your benefits and the
contributions you make for such benefits during the Plan Year. No actual account is established to hold funds; it is
merely a bookkeeping account.
As discussed in Part 4, Q-9 below, you may have the option to elect to participate in a traditional Health FSA or an FSA
limited to vision, dental, and preventive care benefits (a “Limited Health FSA”).
Once you become a participant, you may receive reimbursements for Eligible Medical Expenses incurred by you and
your Eligible Dependents (see Part 4, Q-11 below for more information on Eligible Dependents) unless you elect
otherwise.
Q-3
When does coverage under the Health FSA end?
Participation in the Health FSA continues until i) you elect not to participate; ii) the end of the Plan Year unless you
make an election during the annual election period iii) you no longer satisfy the eligibility requirements described in Part
9 below; (iv) you terminate employment with the employer; or (v) the Plan is terminated or it is amended to exclude you
or the class of employees of which you are a member. You may be entitled to temporarily continue your coverage under
the Health FSA once your coverage ends for certain reasons. See Q-15 below for more information.
POP PLUS FSAS
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SPD (REV. 11/2010)
Q-4
Generally, the rules described in Part 2 Q-5 above apply. However, if your Health FSA coverage ceases during your
FMLA leave, you will be entitled to elect whether to be reinstated in the Health FSA, at the same coverage level in effect
before the FMLA leave (with increased contributions for the remaining period of coverage) or at Health FSA level that is
reduced pro-rata for the period of FMLA leave during which you did not make any contributions. Under either scenario,
expenses incurred during the period that your Health FSA coverage was not in effect are not eligible for reimbursement
under this Health FSA.
Q-5
What happens if I fail to return my Benefit Election Form?
If you are not currently participating in the Plan and fail to return a Benefit Election Form before the end of the
enrollment period, it will be assumed that you have elected to receive your full compensation in cash and you cannot
elect to participate until the next Annual Enrollment Period or you experience a change in status event that permits you
to enroll in the Plan during the Plan Year.
If you have currently elected to participate in a Health FSA, it will be assumed that you do not want to continue
participation in the Health FSA and the deductions will cease as of the first day of the next Plan Year (unless you elect to
stop participating before then).
See Part 2, Q-10 for further discussion.
Q-6
How is my annual election amount credited to my Health FSA?
After you submit a Benefit Election Form specifying the amount you want deducted each pay period, that amount will be
deducted from your pay before applicable federal and state taxes and credited to your Health Care Account each pay
period. This money will be available for reimbursement of eligible medical expenses. The available amount in your
Health Care Account at any particular time will be the total amount elected for the Plan Year under your Health FSA less
any reimbursements you may have already received. For example, if you have elected an annual salary conversion of
$2,400 for eligible Health FSA benefits, then $2,400 would be credited to your Health Care Account during the Plan
Year. If you are paid semi-monthly, $100 a payday (or $200 a month) will be credited to the Health FSA Account to pay
for these expenses, but your reimbursements will not depend on the amount you have contributed. You can file for all or
part of this $2,400 reimbursement at any time during the Plan Year (reduced by reimbursement for expenses incurred
during that Plan Year).
Q-7
What annual benefits are available under the Health FSA, and how much will they cost?
You can choose any amount of annual benefits you desire within the limits set forth in Part 9 below. You will be
required to make annual contributions corresponding to your chosen benefit level.
Q-8
How do I submit a claim for reimbursement under the Health FSA?
Under this Health FSA, you have the method(s) of reimbursement detailed below.
You can complete and submit a written claim for reimbursement (“Traditional Paper Claims”). When you incur an
Eligible Medical Expense, you file a claim with the Plan'
s Third Party Administrator by completing and submitting a
Request for Reimbursement Form. You may obtain a Request for Reimbursement Form from the Plan
Administrator or the Third Party Administrator. You must include with your Request for Reimbursement Form a
written statement from an independent third party (e.g., a receipt, EOB, etc.) associated with each expense that
indicates the following:
a) The nature of the expense (e.g. what type of service or treatment was provided). Effective 1-1-2011, if
the expense is for an over the counter (OTC) drug, the written statement must indicate the name of
the drug and include a doctor’s prescription for same OTC medication;
b) The date the expense was incurred; and
c) The amount of the expense.
You must also certify that you have not been reimbursed for the expense and that you will not seek reimbursement
for it from any other source. You may be required to provide additional documentation if the Plan Administrator (or
its designee) determines that additional information is needed to adjudicate the claim. The PSP will process the
claim once it receives the Request for Reimbursement Form from you. Reimbursement for expenses that are
determined to be Eligible Medical Expenses will be made as soon as possible after receiving the claim and
processing it. If the expense is determined to not be an “Eligible Medical Expense” you will receive notification of
this determination. You must submit all claims for reimbursement for Eligible Medical Expenses during the Plan
Year in which they were incurred or during the Closing Period. The Closing Period is described in the Plan
Information Summary.
POP PLUS FSAS
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SPD (REV. 11/2010)
You may have a claim submitted by means of a provider supplied electronic claim file (“Import”). If you elect this
option when made available to you, you must herby agree not to seek reimbursement for an Imported claims from any
other source.
Alternatively, you may be able to use the mySourceCard® MasterCard® Debit Card (“mySourceCard®”) to pay the
expense. In order to be eligible for the mySourceCard®, you must agree to abide by the terms and conditions of the
mySourceCard® Program (the “Program”) as set forth in Part 7 and in the mySourceCard® Cardholder Agreement (the
“Cardholder Agreement”) including any fees applicable to participate in the program, limitations as to card usage, the
Plan’s right to withhold and offset for ineligible claims, etc.
Q-9
What is an “Eligible Medical Expense”?
General Rule: An “Eligible Medical Expense” is an expense that has been incurred by you and/or your eligible
dependents that satisfies the following conditions:
a. The expense is for "medical care" as defined by Code Section 213(d);
b. You certify that the expense has not been reimbursed by any other source and you will not seek reimbursement for the
expense from any other source.
The Code generally defines "medical care" as any amounts incurred to diagnose, treat or prevent a specific medical
condition or for purposes of affecting any function or structure of the body. This includes, but is not limited to, both
prescription and over the counter drugs (and over the counter products and devices). Effective January 1, 2011 over
the counter (OTC) drugs WILL ONLY be considered as reimbursable expenses if accompanied by a doctor’s
prescription for said OTC medication. Not every health related expense you or your eligible dependents incur
constitutes an expense for “medical care.” For example, an expense is not for “medical care”, as that term is defined by
the Code, if it is merely for the beneficial health of you and/or your eligible dependents (e.g. vitamins or nutritional
supplements that are not taken to treat a specific medical condition) or for cosmetic purposes unless necessary to correct
a deformity arising from illness, injury, or birth defect. You may, in the discretion of the Plan Service Provider/Plan
Administrator, be required to provide additional documentation from a health care provider showing that you have a
medical condition and/or the particular item is necessary to treat a medical condition. Expenses for cosmetic purposes
are also not reimbursable unless they are necessary to correct an abnormality caused by illness, injury or birth defect.
In addition, certain expenses that might otherwise constitute “medical care” as defined by the Code are not reimbursable
under any Health FSA (per IRS regulations):
Health insurance premiums; and
Expenses incurred for qualified long term care services.
Any other expenses that are specifically excluded by the Employer per a list attached and incorporated into the SPD by
the Employer
b. If you currently maintain or wish to establish a personal Health Savings Account: According to rules set forth in
Code Section 223 (applicable to Health Savings Accounts), you will not be able to make/receive tax favored
contributions to your Health Savings Account if you participate in a Health FSA that reimburses general medical
expenses as defined in “a” above. You may, however, be eligible to make/receive tax favored contributions to a personal
Health Savings Account and participate in a Health FSA if the Health FSA reimbursement is limited in scope to the
following unreimbursed Code Section 213(d) expenses (determined in the sole discretion of the Plan Administrator):
•
Services or treatments for dental care (excluding premiums)
•
Services or treatments for vision care (excluding premiums)
•
Services or treatments for “preventive care”.
Preventive care is defined in accordance with applicable rules and regulations. This may include any prescription or
over the counter drugs to the extent such drugs are taken by an eligible individual (i) to delay or prevent the onset of
symptoms of a condition for which symptoms have not yet manifested themselves (i.e. the eligible individual is
asymptomatic) (ii) to prevent the recurrence of a condition from which the eligible individual has recovered or (iii) as
part of a preventive care treatment program (e.g. a smoking cessation or weight loss program). Effective January 1,
2011, over the counter (OTC) drugs WILL ONLY be considered as reimbursable expenses if accompanied by a
doctor’s prescription for said OTC medication. Preventive care does not include services or treatments that treat an
existing condition. Whether a service or treatment constitutes “preventive care” is subject to the sole discretion of the
Plan Administrator.
POP PLUS FSAS
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SPD (REV. 11/2010)
You may make such an election to limit the scope of reimbursement during the Initial Enrollment Period or during the
Annual Enrollment Period described in Part 2 above.
Q-10
How do I receive my payment under the Health FSA?
If your claim for benefits is approved in accordance with the terms of this Plan, you may receive the reimbursement in
one of several ways: (i) a check made payable to you (this check may be written off a Plan Service Provider account;
however, all benefits are paid as needed from the Employer’s general assets) (ii) electronic transfer to your personal
checking or savings account (if offered and if specifically authorized by the participant).
Q-11
Who is an “eligible dependent” for which I can claim expenses for reimbursement?
You can claim reimbursement for eligible medical expenses incurred by your legal spouse (as determined in accordance
with state law to the extent consistent with the federal Defense of Marriage Act), and any individual who would qualify
as a dependent under Code Section 105(b), and any child for whom you are required to provide health coverage pursuant
to a Qualified Medical Support Order (coverage for a child required to be covered as a result of a QMCSO may be
taxable). Also, children of divorced parents are considered to be a dependent of both parents to the extent that both
parents together provide over half of the child’s support and the child resides with one of the parents.
If your spouse maintains a Code Section 223 health savings account or wishes to establish a Code Section 223 health
savings account, your participation in this Health FSA (to the extent reimbursement under this Health FSA is not
restricted as described in Q-9(b) above) may cause your spouse to be ineligible for a Code Section 223 health savings
account if your spouse and/or your “dependents” are covered under this Health FSA. In that case, you may make a
prospective election at any time to exclude your dependents from coverage and cover only yourself under this Health
FSA. You may make such an election to limit the scope of eligible dependents during the Initial Enrollment Period or
during the Annual Enrollment Period described in Part 2 above.
Q-12
When must a reimbursable expense be incurred?
Eligible expenses reimbursed under the Plan must be incurred during the Participant'
s period of coverage under the Plan.
Expenses are treated as having been incurred when the Participant is provided with the medical care that gives rise to the
medical expenses, not when the Participant is formally billed or charged for the services or pays for the medical care.
During your current participation year, you cannot be reimbursed for any expenses incurred before the Plan Effective
Date, before your Salary Reduction and Election Form becomes effective, expenses incurred after the date that you stop
being eligible under this Health FSA (except as described in Part 5, Q-14 below) or for any expense incurred after the
close of the Plan Year.
Q-13
Can I change the election during the year?
Only if you experience one of the qualifying events listed in Part 2, Q-11 and follow the procedures outlined within that
section.
Q-14
What happens if I still have a balance in my Account at the end of the Plan Year?
Any unused amounts left in your Account at the end of the Plan Year will be forfeited and returned to your employer to
offset administrative expenses and future costs. Also, any uncashed reimbursement checks will be forfeited if not cashed
within 90 days of issue.
Q-15
Can I continue coverage in my Account?
Federal law requires most employers sponsoring group health plans to offer employees and their families the opportunity
for a temporary extension of health care coverage (called “continuation coverage” or COBRA) at group rates in certain
instances where coverage under the plans would otherwise end. These rules apply to the Health FSA, unless the
Employer is a small-employer within the meaning of the applicable regulations. The Plan Administrator can tell you
whether the Employer is a small employer (and thus not subject to these rules).
If you are a participant in the Health FSA, then you have a right to choose continuation coverage under the Health FSA if
you lose your coverage because of:
•
a reduction in your hours of employment;
•
a voluntary or involuntary termination of your employment (for reasons other than gross misconduct), or
•
a military leave of absence (in accordance with USERRA).
If you are the spouse of a Participant, then you have the right to choose continuation coverage for yourself if you lose
coverage for any of the following reasons:
•
POP PLUS FSAS
The death of your spouse;
PAGE 13
SPD (REV. 11/2010)
•
A voluntary or involuntary termination of your spouse'
s employment (for reasons other than gross
misconduct) or reduction in your spouse'
s hours of employment; or
•
The divorce or legal separation from your spouse.
In the case of a Dependent child of a participant, he or she has the right to choose continuation coverage if coverage is
lost for any of the following reasons:
•
The death of the employee;
•
A voluntary or involuntary termination of the employee'
s employment (for reasons other than gross
misconduct) or reduction in the employee'
s hours of employment;
•
His or her parents'divorce or legal separation; or
•
He or she ceases to be a dependent child.
A child who is born to, or placed for adoption with, the employee during a period of continuation coverage is also
entitled to continuation coverage under COBRA provided the child is properly enrolled. Those who are entitled to
continue coverage under COBRA are called “Qualified Beneficiaries”
If you choose continuation coverage, you may continue the level of coverage you had in effect immediately preceding
the qualifying event. However, if Plan benefits are modified for similarly situated active employees, then they will be
modified for you and other Qualified Beneficiaries as well. You will be eligible to make a change in your benefit
election with respect to the Plan upon the occurrence of any event that permits a similarly situated active employee to
make a benefit election change during a Plan Year.
If you do not choose continuation coverage, your coverage under the Health FSA will end with the date you would
otherwise lose coverage.
You or your covered dependents (including your spouse) must notify the employer of a divorce, legal separation, or a
child losing dependent status under the Plan within 60 days of the later of the date of the event or the date on which
coverage is lost because of the event. Your written notice should identify the qualifying event date on which the event
occurred and the qualified beneficiaries impacted by the qualifying event. When the COBRA Administrator, as
identified in the Plan Information Summary, is notified in writing that one of these events has occurred, the COBRA
Administrator will in turn notify you that you have the right to choose continuation coverage. Notice to an employee'
s
spouse is treated as notice to any covered Dependents who reside with the spouse.
The COBRA Participant and/or covered dependent are responsible for notifying the Plan Administrator if he or she
becomes covered under another group health plan.
Each qualified beneficiary is entitled to make a separate election for continuation coverage under the Plan. The covered
employee who is a qualified beneficiary may elect coverage for all other qualified beneficiaries; however, the covered
employee may not decline coverage for a qualified beneficiary spouse. A parent or guardian may elect coverage for a
minor dependent child who is a qualified beneficiary. In order to elect continuation coverage, you must complete the
election form(s) provided to you by the Plan Administrator. You have 60 days from the date you would lose coverage for
one of the reasons described above or the date you are sent notice of your right to elect continuation coverage, whichever
is later, to inform the Plan Administrator that you wish to continue coverage. Failure to return the election form within
the 60-day period will be considered a waiver, and you will not be allowed to elect continuation coverage.
You will have to pay the entire cost of your continuation coverage. The cost of your continuation coverage will not
exceed 102% of the applicable premium for the period of continuation coverage. The first premium payment after
electing continuation coverage will be due 45 days after making your election. Subsequent premiums must be paid
within a 30-day grace period following the due date. Failure to pay premiums within this time period will result in
automatic termination of your continuation coverage. Claims incurred during any period will not be paid until your
premium payment is received for that period. If you timely elect continuation coverage and pay the applicable premium,
however, then continuation coverage will relate back to the first day on which you would have lost regular coverage.
The maximum period for which coverage may be continued will be until the end of the Plan Year in which the qualifying
event occurs. To the extent that Non-elective Employer contributions are provided, the maximum duration of coverage
may be 18 or 36 months from the qualifying event (depending on the type of qualifying event). You will be notified of
the duration of continuation coverage when you have a qualifying event. However, continuation coverage may end
earlier for any of the following reasons:
•
POP PLUS FSAS
The contribution for your continuation coverage is not paid on time or it is insufficient (Note: If your
payment is insufficient by the lesser of 10% of the required COBRA premium, or $50, you will be given 30
days to cure the shortfall);
PAGE 14
SPD (REV. 11/2010)
Q-16
•
The date that you first become covered under another group health plan under which you are not subject to a
pre-existing condition exclusion limitation, after you elect continuation coverage;
•
The date that you first become entitled to Medicare, after you elect continuation coverage; or
•
The date the employer no longer provides group health coverage to any of its employees.
What happens if a claim for benefits under the Health FSA is denied?
If you are denied a benefit under the Health FSA, you should proceed in accordance with the following claims review
procedures.
Step 1:
of the claim. For reasons beyond the control of the Plan Service Provider, the Plan Service Provider may take up to an
additional 15 days to review your claim. You will be provided written notice of the need for additional time prior to the
end of the 30-day period. If the reason for the additional time is that you need to provide additional information, you will
have 45 days from the notice of the extension to obtain that information. The time period during which the Plan Service
Provider must make a decision will be suspended until the earlier of the date that you provide the information or the end
of the 45-day period.
Step 2:
•
•
A description of any additional information necessary for you to perfect your claim, why the information is
necessary, and your time limit for submitting the information;
•
•
Step 3:
If you disagree with the decision, file an Appeal. If you do not agree with the decision of the Plan Service
Provider, you may file a written appeal. You should file your appeal no later than 180 days of receipt of the notice
described in Step 1. If the Plan has established only one level of review, you should file your appeal with the Plan
Administrator. If the Plan has established two levels of appeal, you should file your appeal with the Plan Service
Provider. The notice of denial reference in Step 1 above will indicate whether the plan has 1 or 2 levels of appeal.
Regardless, you should submit all information identified in the notice of denial as necessary to perfect your claim and
any additional information that you believe would support your claim.
Step 4:
Notice of Denial is received from claims reviewer. If the claim is again denied, you will be notified in
writing. If the plan has established two levels of appeal as set forth in the notice of denial, the notice will be sent no later
than 30 days after receipt of the appeal by the Plan Service Provider. Otherwise, notice of the denial will be sent no later
than 60 days after the appeal is received by the Plan Administrator.
Step 5:
Review your notice carefully. You should take the same action that you take in Step 2 described above. The
notice will contain the same type of information that is provided in the first notice of denial provided by the Plan Service
Provider.
Step 6 (if there is a second level of appeal as indicated in the notice of denial): If you still disagree with the Plan
Service Provider’s decision, file a 2nd Level Appeal with the Plan Administrator. If you still do not agree with the Plan
Service Provider’s decision, you may file a written appeal with the Plan Administrator within the allotted number of days
set forth in the notice of denial from the Plan Service Provider. You should gather any additional information that is
identified in the notice as necessary to perfect your claim and any other information that you believe will support your
claim.
If the Plan Administrator denies your 2nd Level Appeal, you will receive notice within 30 days after the Plan
above.
Important Information
Other important information regarding your appeals:
•
Each level of appeal will be independent from the previous level (i.e. the same person(s) or subordinates of
the same person(s) involved in a prior determination will not be involved in a subsequent decision);
•
On each level of appeal, the claims reviewer will review relevant information that you submit even if it is new
information;
POP PLUS FSAS
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SPD (REV. 11/2010)
•
Q-17
You cannot file suit in federal court until you have exhausted these appeals procedures.
Will my health information be kept confidential?
Under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), group health plans such as the
Health FSA and the third party service providers are required to take steps to ensure that certain “protected health
information” is kept confidential. You may receive a separate notice that outlines the health privacy policies of the Plan.
Part 5. Dependent Care Assistance Benefit
Another component of your Employer'
s Cafeteria Plan, if listed as a benefit offered under the Plan in Part 9 below, is the
Dependent Care Assistance Plan. Participation in this Plan allows you to receive income tax-free reimbursement for
some or all of your work-related dependent care expenses under a related Dependent Care Assistance Plan (DCAP). A
DCAP allows you to provide a source of pre-tax funds to reimburse you for your eligible expenses. You do this by
entering into a salary conversion agreement (Benefit Election Form) with the Employer instead of receiving a
corresponding amount of your regular pay. This arrangement saves you money; you pay less Social Security and income
taxes because the salary conversion paying for your elected benefits is not taxable.
Q-1
Who can participate in a DCAP?
If you are eligible to be a participant in the Cafeteria Plan, you can participate in the DCAP. If you are married, your
spouse must also work, go to school full time, or be incapable of self-care for you to be eligible.
Q-2
You can participate by electing the DCAP Benefit during the applicable Enrollment Periods. See Part 2, Q-8 for your
effective date of participation. Effective dates of participation vary by Enrollment Period. Once you elect benefits under
this DCAP, a Dependent Care Expense Reimbursement Account (DCAP Account) will be set up in your name to record
your benefits and the contributions you make for such benefits during the Plan Year.
Q-3
When does coverage under the DCAP end?
You continue to participate in the Dependent Care FSA until (i) you elect not to participate; (ii) you no longer satisfy the
eligibility requirements described in the Plan Information Summary; (iii) the end of the Plan Year unless you make an
election to participate during the annual election period; (iv) you terminate employment with the employer (there are
special rules for terminating employees), or (v) the Plan is terminated or amended to exclude you or the class of
employees of which you are a member. However, you may be able to continue to submit claims for reimbursements for
Eligible Employment Related Expenses incurred after the date that you terminate employment up to balance in your
Dependent Care Account as of the date you terminate employment.
Q-4
Generally, the rules described in Part 2 Q-5 above of this SPD apply to the Dependent Care FSA.
Q-5
What happens if I fail to return my Benefit Election form?
If you are not currently participating in the Plan and fail to return a Benefit Election Form before the end of the
enrollment period, it will be assumed that you have elected to receive your full compensation in cash and you cannot
become a Participant until the next Plan Year. The only exception to this is if you have experienced one of the qualifying
events listed in Part 2, Q-11 above. If so, you must submit an Employee Statement of Qualifying Event form (stating the
event) and a Personal Benefit Election Change Request Form (stating the changes in elections) within 30 days of the
event to enroll.
If you have currently elected to participate in a DCAP and you fail to return the Benefit Election Form, it will be
assumed that you do not want to continue participation in the DCAP and the deductions will cease.
See Part 2, Q-10 above for further discussion.
Q-6
How is my annual election amount credited to my DCAP Account?
After you submit a Benefit Election Form specifying the amount you want deducted each pay period, that amount will be
deducted from your pay and credited to your DCAP Account each pay period. This money will be available for
reimbursement of your dependent care expenses. The available amount in your DCAP Account at any particular time
will be the amount credited to your DCAP Account to date less any reimbursements you may have already received.
Q-7
Are there any other limits on what DCAP benefits are tax free?
In addition to the dollar limitations in Part 9 below, the maximum amount of DCAP benefits you may exclude from
income during any calendar year cannot be more than:
If you are not married as of the end of the year, your earned income for the year, or
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SPD (REV. 11/2010)
If you are married at the end of the year, the lesser of your earned income for the year, or your spouse’s earned
income.
Q-8
Is there any other way I can save taxes on my DCAP expenses?
Yes, you can claim the Household and Dependent Care Credit when filing your federal income tax return.
Q-9
What is the Household and Dependent Care Credit?
The household and dependent care credit is an allowance for a percentage of your annual, Eligible Employment Related
Expenses as a credit against your federal income tax liability under the U.S. Tax Code. In determining what the tax credit
would be, you may take into account only $3,000 of such expenses for one Qualifying Individual, or $6,000 for two or
more Qualifying Individuals. Depending on your adjusted gross income, the percentage could be as much as 35% of your
Eligible Employment Related Expenses (to a maximum credit amount of $1050 for one Qualifying Individual or $2100
for two or more Qualifying Individuals,) to a minimum of 20% of such expenses. The maximum 35% rate must be
reduced by 1% (but not below 20%) for each $2,000 portion (or any fraction of $2,000) of your adjusted gross incomes
over $15,000.
Illustration: Assume you have one Qualifying Individual for whom you have incurred Eligible Employment Related
Expenses of $3,600, and that your adjusted gross income is $21,000. Since only one Qualifying Individual is involved,
the credit will be calculated by applying the appropriate percentage to the first $3,000 of the expenses. The percentage is,
in turn, arrived at by subtracting one percentage point from 35% for each $2,000 of your adjusted gross income over
$15,000. The calculation is: 35% -- [($21,000 - 15,000)/$2,000 X 1%] = 32%. Thus, your tax credit would be $3,000 X
32% = $960. If you had incurred the same expenses for two or more Qualifying Individuals, your credit would have been
$3,600 X 32% = $1152, because the entire expense would have been taken into account, not just the first $3,000.
Q-10
If I participate in the DCAP, can I claim the Household and Dependent Care Credit on my federal
income tax return?
If you participate in both, each dollar that you receive under the DCAP FSA reduces the amount of expenses that may be
taken into consideration under the Household and Dependent Care Credit (that is, the $3,000 and $6,000 amount).
Example: If you had $5,000 in dependent care expenses for 2001 for two children, but only elected $2000 for your
DCAP, you would still be eligible for a partial tax credit. You would calculate your tax credit by subtracting $2,000
(amount reimbursed by DCAP) from $6000 (the maximum allowed for the Household and Dependent Care Credit). This
would leave you with $4000, your basis for the Household and Dependent Care Credit. You would then apply the
formula for the credit as stated in Q-9 above.
Example: If you had $10,000 in dependent care expenses for 2001 and claimed the maximum $5,000 under a DCAP, you
cannot claim the other $5,000 as a Household and Dependent Care Credit on your federal income tax return.
Q-11
Under what circumstances can I receive reimbursement under the DCAP”?
You can be reimbursed for work-related dependent care expenses provided all the following conditions are satisfied:
1. The expenses are for services rendered after the date of your Dependent Care election and before the end of the Plan
Year.
2. The individual for whom you incurred the expenses is a “Qualifying Individual”. A “Qualifying Individual” is a:
•
An individual age 12 or under who (i) has the same principal place of abode as you, (ii) does not provide over
half of his/her own support and (iii) is your “child” (son, daughter, grandchildren, step-children, brother, sister,
niece and nephew). Note: There is a special rule for children of divorced parents. If you are divorced, the
child is a qualifying individual with respect to you if the child lives with you even if you have permitted the
non-custodial parent to take the personal tax exemption; or
•
A Spouse or other tax Dependent (as defined in Code Section 152) who is physically or mentally incapable of
caring for himself or herself and who has the same principal place of abode as you for more than half of the
year.
3. The expenses are incurred to enable you to be gainfully employed.
4. If the expenses are incurred for services outside your household for a Dependent who is age 13 or older, that
Dependent must spend at least 8 hours a day in your home.
5. If the incurred expenses are for services provided by a dependent care center (that is, a facility that provides care for
more than six individuals not residing at the facility), the center must comply with all applicable state and federal laws.
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SPD (REV. 11/2010)
6. The expenses cannot be paid or payable to a child of yours who is under age 19 at the end of the year when the
services were rendered or to an individual for whom you or your spouse is entitled to a personal tax exemption as a
dependent.
7. This reimbursement (plus all other Dependent Care reimbursements during the same year) may not exceed the least of
the following limits:
•
$5,000,
•
$2,500 if you are married, but you and your Spouse file separate tax returns,
•
Your taxable compensation (after your salary reduction under the Plan), or
•
If you are married, your Spouse’s actual or deemed earned income.
Your Spouse will be deemed to have earned income of $250 (for one Eligible Dependent) or $500 (for two Eligible
Dependents) for each month the Spouse is either (1) physically or mentally incapable of personal care or (2) a full-time
student. Your spouse is considered to be a full-time student if the spouse is deemed a full-time student by the
“educational institution” attended by the spouse during each of five calendar months during a Plan Year. An educational
institution is any educational institution that normally maintains a regular faculty and curriculum and normally has a
regularly enrolled body of students in attendance at the place where its educational activities are regularly carried on.
You are encouraged to consult your personal tax advisor or IRS Publication 17 “Your federal Income Tax” for further
information or clarification.
Q-12
How do I submit a claim for reimbursement under the DCAP?
Under this DCAP, you have types of reimbursement options detailed below.
You can complete and submit a written claim for reimbursement (“Traditional Paper Claims”). When you incur an
Eligible Employment Related Expense, you file a claim with the Plan Service Provider by completing and submitting a
Request for Reimbursement Form. You may obtain a Request for Reimbursement Form from the Plan Service Provider.
You must include with your Request for Reimbursement Form a written statement from an independent third party (e.g.
a receipt or invoice) associated with each expense that indicates the following:
a)
The date the expense was incurred
b) The amount of the expense.
The amount of your reimbursement will depend on your current Account Balance (deductions to date minus any
previous reimbursements). If your Account Balance is equal to or exceeds your claim, your claim for eligible expenses
will be reimbursed in full. If your claim exceeds your current Account balance, the excess part of the claim will be
carried over into the following pay cycles to be paid as your balance can cover it. In other words, as additional salary
conversion amounts are credited to your Account raising your Account Balance, a reimbursement check will be
processed automatically for any unpaid portions of any properly submitted claims. Remember, no expenses can be
reimbursed that exceeds the payments you have made up to that date minus any previous reimbursements.
You cannot be reimbursed for any expenses incurred before the Plan Effective Date, before your Benefit Election Form
becomes effective, or after the end of the Plan Year. You may be able to submit claims for reimbursement of an eligible
expense incurred after the date that you terminate or cease to be eligible for this Plan up to your account balance on the
date that you stopped being eligible. Also, no check will be written if the current amount payable to the Participant for
claims is less than the Minimum Check Amount as specified in Part 9 below. The Minimum Check Amount will not
apply for processing the final checks during any Plan Year.
At the end of the Plan Year, you will have a closing period (as stated in Part 9 below) to turn in claims for expenses
incurred during the Plan Year. No claims can be submitted for reimbursement after the closing period ends. Your
Employer may set a claims submission grace period for terminated employees; if so, you will find this information in
Part 9 below.
Q-13
Will I be taxed on the DCAP benefits I receive?
You will not normally be taxed on your DCAP benefits up to the limits set out in Part 5, Q-7 and Part 5, Q-9. However,
before you can qualify for tax-free treatment, you are required to list the names and taxpayer identification numbers of
any persons providing your dependent care services during the calendar year for which you have claimed a tax-free
reimbursement. (Be sure to fill out all the spaces on your claim!)
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SPD (REV. 11/2010)
Q-14
Can I change my election if I change day care providers during the year and the rates are
different?
Yes, this will be considered a Change of Coverage (see Part 2, Q-11). You will need to submit an Employee Statement of
Qualifying Event form (stating the event) and a Personal Benefit Election Change Request Form (stating the changes in
elections) within 30 days of the event to change the day care provider and the rates.
Q-15
Can I change my election if a relative starts keeping my children for free?
Yes, this will also qualify for the Change of Coverage discussed above. You would submit a Change of Status Form
changing providers with the rate being changed to zero. NOTE: You will not be able to change your election as a result
of a cost increase or decrease imposed by a relative.
Q-16
What happens if I still have a balance in my DCAP Account at the end of the Plan Year?
Any unused amounts left in your Account at the end of the Plan Year cannot be carried over into the next year, but will
be forfeited and returned to your employer to offset administrative expenses and future costs. Also, any uncashed
reimbursement checks will be forfeited if not cashed within 90 days of issue.
Q-17
What happens if my claim for DCAP benefits is denied?
If you are denied a claim reimbursement under the Plan (e.g. election changes, eligibility for pre-tax benefits), you
should proceed in accordance with the following claims review procedures. If you are denied a claim under one of the
Benefit Package Options, you should proceed in accordance with the claims review procedures established for that
particular Benefit Package Option.
Step 1:
of the claim. For reasons beyond the control of the Plan Service Provider, the Plan Service Provider may take up to an
additional 15 days to review your claim. You will be provided written notice of the need for additional time prior to the
end of the 30-day period.
Step 2:
A description of any additional information necessary for you to perfect your claim, why the information is necessary,
Step 3:
If you disagree with the decision, you may file an appeal. If you do not agree with the decision of the Plan
Service Provider, you may file a written appeal. You should file your appeal no later than 180 days of receipt of the
notice described in Step 1. If the Plan has established only one level of review, you should file your appeal with the Plan
Administrator. If the Plan has established two levels of appeal, you should file your appeal with the Plan Service
Provider. The notice of denial reference in Step 1 above will indicate whether the plan has 1 or 2 levels of appeal.
Regardless, you should submit all information identified in the notice of denial as necessary to perfect your claim and
any additional information that you believe would support your claim.
Step 4:
Notice of Denial is received from claims reviewer. If the claim is again denied, you will be notified in
writing. If the plan has established two levels of appeal as set forth in the notice of denial, the notice will be sent no later
than 30 days after receipt of the appeal by the Plan Service Provider. Otherwise, notice of the denial will be sent no later
than 60 days after the appeal is received by the Plan Administrator.
Step 5:
Review your notice carefully. You should take the same action that you take in Step 2 described above. The
notice will contain the same type of information that is provided in the first notice of denial provided by the Plan Service
Provider.
Step 6 (if there is a second level of appeal as indicated in the notice of denial): If you still disagree with the Plan
Service Provider’s decision, file a second level appeal with the Plan Administrator. If you still do not agree with the Plan
Service Provider’s decision, you may file a written appeal with the Plan Administrator within the time allotted for
appealing as set forth in the notice of denial from the Plan Service Provider. You should gather any additional
information that is identified in the notice as necessary to perfect your claim and any other information that you believe
will support your claim.
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SPD (REV. 11/2010)
If the Plan Administrator denies your second level appeal, you will receive notice within 30 days after the Plan
above.
Q-18
How do I receive my payment under the DCAP?
If your claim for benefits is approved in accordance with the terms of this Plan, you may receive the reimbursement in
one of several ways: (i) a check made payable to you (this check may be written off a Plan Service Provider account;
however, all benefits are paid as needed from the Employer’s general assets) (ii) electronic transfer to your personal
checking or savings account (if offered and if specifically authorized by the participant).
Part 6. Health Savings Account Contributions
Another component of your Employer'
s Cafeteria Plan, if listed as a benefit offered under the Plan in Part 9 below, is the
ability to make tax-free contributions to your Health Savings Account (HSA) that you establish with a custodian or
trustee. For more information concerning the tax ramifications of participating in an HSA as well as the terms and
conditions of your HSA see the communications materials provided by your HSA custodian/trustee.
Q-1
What is a Health Savings Account for which contributions can be made under this Plan?
A Health Savings Account (“HSA”) is a personal savings account established with a Custodian or Trustee to be used
primarily for reimbursement of “eligible medical expenses” you (the Account Beneficiary) and your eligible tax
dependents (as defined in Code Section 152) incur, as set forth in Code Section 223. The HSA is administered by the
HSA Custodian or Trustee or its designee and the terms of the HSA are set forth in the Custodial or Trust Agreement.
The HSA is not an Employer sponsored employee benefit plan. The Employer’s role with respect to the HSA is limited
to making an HSA available to you and to making contributions to the HSA on your behalf through this Plan (through
non-elective Employer contributions and/or pre-tax salary reductions elected by the Account Beneficiary). The fact that
contributions to the HSA are made through this Plan should not be construed as endorsement of the HSA by the
Employer. The Employer has no authority or control over the funds deposited in the Account Beneficiary’s HSA. As
such, the HSA identified in the Plan Information Summary is not subject to the Employee Retirement Income Security
Act of 1974 (ERISA).
Q-2
Who is eligible for an HSA?
Only individuals who satisfy the following conditions are eligible for an HSA offered under this Plan:
(a) You are enrolled in a qualifying High Deductible Health Plan maintained by your Employer that is identified as
a benefit plan option in the Plan Information Summary;
(b) You have opened an HSA with the Custodian chosen by the Employer;
(c) You are not covered under any other non-high deductible health plan maintained by the Employer that is
determined by the Employer to offer disqualifying health coverage [Note that you are not eligible for an HSA if
you are covered under any non-qualifying coverage whether maintained by the Employer or not (including but
not limited to coverage maintained by your spouse’s employer) and it is solely your responsibility to ensure that
any other coverage you have that is not maintained by the Employer qualifies under Code Section 223] and
(d) You have certified that you are otherwise eligible to participate in the HSA (i.e., you: i) cannot be claimed as a
tax dependent; ii) are not enrolled in Medicare coverage; iii) have qualifying high deductible health plan
coverage; and iv) have no disqualifying coverage from any other source); and
(e) You are otherwise eligible for this Plan.
Q-3
Who is an Account Beneficiary?
An Account Beneficiary is an eligible Participant who has properly enrolled in an HSA in accordance with the terms of
the applicable Custodial Agreement.
Q-4
Who is a Custodian or Trustee?
The Custodian or Trustee is the entity with whom the Account Beneficiary’s HSA is established (for purposes of this
Plan, use of the term “Custodian” includes a reference to both Custodian and Trustee). The HSA is not sponsored by or
maintained by the Employer. The Custodian or its designee will provide each Account Beneficiary with a Custodial
Agreement and other information that describes how to enroll in the HSA and your rights and obligations under the HSA
The Employer may choose to restrict contributions made through this Plan to HSAs maintained by a particular
Custodian; however, you will be permitted to rollover funds from the HSA offered under this Plan to another HSA of
your choosing (in accordance with the terms of the Custodial Agreement).
Q-5
What are the rules regarding contributions made to an HSA under the Plan?
Contributions made under this Plan may consist of both employee pre-tax contributions made pursuant to a Salary
Reduction Agreement and/or non-elective Employer contributions (if any). You may elect to contribute any amount to
POP PLUS FSAS
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SPD (REV. 11/2010)
the HSA that you wish; however, the maximum amount of all contributions that can be made to the HSA through this
Plan (including both Employer non-elective and pre-tax salary reductions) during the Plan Year cannot exceed:
• the maximum amount set forth in Code Section 223(b)(2) (as adjusted for inflation)
• any other amount established by the Employer in the HSA communication material
If the Account Beneficiary is age 55 or older and the Account Beneficiary properly certifies his or her age to the
Employer, the maximum contribution amount described above may be increased by the “additional annual contribution”
amount (as set forth in Code Section 223(b)(3)), but only to the extent set forth in the separate written HSA material
provided by the Employer and/or the Custodian.
To the extent set forth in the Plan’s enrollment material or the HSA communication material, the Employer may
automatically withhold pre-tax contributions from your compensation to contribute to an HSA unless you affirmatively
indicate that you do not wish to contribute to the HSA with pre-tax contributions. Pre-tax contributions will equal the
maximum annual contribution amount set forth above (reduced by any Employer non-elective contributions) divided by
the number of pay periods remaining during the Plan Year. Non-elective Employer contributions may be made at any
time during the Plan Year in a lump sum amount or through periodic contributions (as determined in the sole discretion
of the Employer) and communicated in Plan or HSA enrollment materials.
Your HSA election under this Plan will not be effective until the later of the date that you make your election or the date
that you establish your HSA. Employer may adjust contributions made under this Plan as necessary to ensure the
maximum contribution amount is not exceeded.
Any pre-tax contributions that cannot be made to the HSA because you have been determined to be ineligible for such
contribution will be returned to you as taxable compensation or as otherwise set forth in the Plan enrollment material.
Any non-elective contributions that cannot be made to the HSA because the employee is not eligible for such
contribution will be returned to the Employer except as otherwise set forth in the applicable communication material.
Q-6
What are the election change rules under this Plan for HSA elections?
You may change your HSA contribution election at any time during the plan year for any reason by submitting an
election change form to the Plan Administrator (or its designee). Your election change will be prospectively effective as
of the first day of the next pay period following the day that you properly submit your election change (or such later date
as uniformly applied by the Plan Administrator to accommodate payroll changes). Your ability to make pre-tax
contributions under this Plan to the HSA ends on the date that you cease to meet the eligibility requirements under this
Plan.
Q-7
Where Can I get More Information on My HSA and its Related Tax Consequences?
For details concerning your rights and responsibilities with respect to your HSA (including information concerning the
terms of eligibility, qualifying High Deductible Health Plan, contributions to the HSA, and distributions from the HSA),
please refer to your HSA Custodial Agreement and/or the HSA communication material provided by your Employer.
Part 7. mySourceCard®
The Electronic Payment Card allows you to pay for Eligible Expenses as defined by the Plan(s) in which you participate at
the time that you incur the expense. Here is how the Electronic Payment Card works, if indicated as an option under the Plan
in Part 9 below.
(a) You must make an election to use the card. In order to be eligible for the Electronic Payment Card, you must agree
to abide by the terms and conditions of the Program as set forth herein and in the Electronic Payment Cardholder
Agreement (the “Cardholder Agreement”) including any fees applicable to participate in the Program, limitations as
to card usage (it cannot be used at all MasterCard® acceptance locations and has no cash assess), the Plan’s right to
withhold and offset for ineligible claims, etc. You must agree to abide by the terms of the Program both during the
Initial Election Period and during each Annual Election Period. A Cardholder Agreement will be provided to you
when you card is provided to you. The card will be effective the first day of each Plan Year unless you do not
affirmatively opt-out of the Program during the preceding Annual Election Period. The Cardholder Agreement is
part of the terms and conditions of your Plan and this SPD.
(b) The card will be turned off when employment or coverage terminates. The card will be turned off when you
terminate employment or coverage under the Plan. You may not use the card during any applicable COBRA
continuation coverage period.
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SPD (REV. 11/2010)
(c) You must certify proper use of the card. As specified in the Cardholder Agreement, you certify during the
applicable Election Period that the amounts in your Plan will only be used for Eligible Expenses (i.e. medical care
expenses incurred by you, your spouse, and your tax dependents) and that you have not been reimbursed for the
expense and that you will not seek reimbursement for the expense from any other source. Failure to abide by this
certification will result in termination of card use privileges.
(d) Reimbursement under the card is limited to specific providers. Use of the card for Health FSA expenses is limited
to merchants who are health care providers (doctors, pharmacies, etc.). As set forth in the Cardholder Agreement,
you will not be able to use the card at a regular retail store – e.g., a supermarket, grocery store, or discount store with
a pharmacy that is not an IIAS participating provider. Use of the card for other Plan expenses may be limited to
merchants of qualified classifications. The card cannot be used at all MasterCard® acceptance locations.
(e) You swipe the card at the provider like you do any other credit or debit card. When you incur an Eligible Expense
at a qualified merchant, you swipe the card much like you would a typical credit or debit card. The provider is paid
for the expense up to the maximum reimbursement amount available under the Plan (or as otherwise limited by the
Program) at the time that you swipe the card. Every time you swipe the card, you certify to the Plan that the expense
for which payment under the Plan is being made is an Eligible Expense and that you have not been reimbursed from
any other source nor will you seek reimbursement from another source.
(f) You must obtain and retain a receipt/third party statement each time you swipe the card. You must obtain a third
party statement from the provider (e.g., receipt, invoice, etc.) that includes the following information each time you
swipe the card:
•
•
•
The nature of the expense (e.g., what type of service or treatment was provided).
The date the expense was incurred.
The amount of the expense.
You must retain this receipt for one year following the close of the Plan year in which the expense is incurred. Even
though payment is made under the card arrangement, a written third party statement may be required to be
submitted. You will receive written notice from the Plan Service Provider that a third party statement is needed in
order to substantiate the expense. If requested by the Plan Service Provider, you must provide the third party
statement within 30 days (or other period specified in the notice) of the request.
(g) There are situations where the third party statement will not be required to be provided to the Plan Service
Provider. There are many situations in which you will not be required to provide the written statement to the Plan
Service Provider. Situations in which you may not be required to submit the third party statement are detailed in the
Cardholder Agreement.
Note: You must obtain the third party receipt for ALL card transactions when you incur the expense and swipe the
card, even if you think it will not be needed, so that you will have it in the event the Plan Service Provider or the IRS
requests it.
(h) You must pay back any improperly paid claims. If you are unable to provide adequate or timely substantiation as
requested by the Plan Service Provider, you must repay the Plan for the unsubstantiated expense. The deadline for
repaying the Plan is determined by the Plan Administrator. If you do not repay the Plan within the applicable time
period, the card will be turned off and an amount equal to the unsubstantiated expense will be offset against future
eligible claims under the Plan. If no claims are submitted prior to the date you terminate coverage in the Plan, or
claims are submitted but they are not sufficient to cover the unsubstantiated expense amount, then the amount may
be withheld from your pay (as specified in the Cardholder Agreement) or the remaining unpaid amount will be
included in your gross income as taxable “wages.”
You can use either the payment card or the traditional paper claims approach. You have the choice as to how to submit
your eligible claims. If you elect not to use the electronic payment card, you may also submit claims under the
Traditional Paper Claims approach discussed above. Claims for which the Electronic Payment Card has been used
cannot be submitted as Traditional Paper Claims.
POP PLUS FSAS
PAGE 22
SPD (REV. 11/2010)
Part 8. ERISA Rights
This Plan is not a welfare benefit plan as defined in the Employee Retirement Income Security Act (ERISA). However,
certain component benefits (such as the Health FSA Plan) may be governed by ERISA. ERISA provides that you, as a Plan
Participant, will be entitled to:
1. Receive Information about Your Plan and Benefits
•
Examine, without charge, at the Plan Administrator'
s office and at other specified
locations, such as worksites and union halls, all documents governing the plan,
including insurance contracts, collective bargaining agreements, and a copy of the
latest annual report (Form 5500 series) filed by the Plan with the U.S. Department of
Labor and available at the Public Disclosure Room of the Employee Benefits Security
Administration.
•
Obtain, upon written request to the plan administrator, copies of all documents
governing the operation of the plan, including insurance contracts and collective
bargaining agreement, and copies of the latest annual report (Form 5500 series) and
updated Summary Plan Description. The Plan Administrator may make a reasonable
charge for the copies.
•
Receive a summary of the Plan'
s annual financial report. The Plan Administrator is
required by law to furnish each participant with a copy of this summary annual report.
2. Continue Group Health Plan Coverage
•
Continue health coverage for you, your spouse, or your dependents if there is a loss of
coverage under the plan as a result of a qualifying event. However, you or your
dependents may have to pay for such coverage. Review this Summary Plan Description
and the documents governing the Plan on the rules governing your COBRA
continuation coverage rights.
•
Obtain reduction or elimination of exclusionary periods of coverage for preexisting
conditions under your group health plan, if you have creditable coverage under another
plan (if the Health FSA is subject to HIPAA). You should be provided a certificate of
creditable coverage, free of charge, from your group health plan or health insurance
issuer when you lose coverage under the Plan, when you become entitled to elect
COBRA continuation coverage, when your COBRA continuation coverage ceases (if
you requested continuation coverage), before losing coverage (if you requested
continuation coverage), or up to 24 months after losing coverage (if you requested
continuation coverage). Without evidence of creditable coverage, you may be subject
to preexisting condition exclusion for 12 months (18 months for late enrollees) after
your enrollment date in your coverage.
3. Prudent Actions by Plan Fiduciaries
In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the
operation of the Employee Benefit Plan. The people who operate your Plan, called "fiduciaries" of the Plan, have a duty
to do so prudently and in the interest of the Plan participants and beneficiaries. No one, including your employer, your
union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining
a welfare benefit from the Plan, or from exercising your rights under ERISA.
4. Enforcement of Your Rights
If your claim for a welfare benefit under an ERISA-covered plan is denied in whole or in part, you must receive
a written explanation of the reason for the denial. You have the right to have the Plan review and reconsider
your claim. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request
materials from the Plan and do not receive them within 30 days, you may file suit in a federal court. In such a
case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until
you receive the materials, unless the materials were not sent because of reasons beyond the control of the
Administrator. If you have a claim for benefits that is denied or ignored in whole or in part, you may file suit in
a state or federal court. In addition, if you disagree with the plan’s decision or lack thereof concerning the
qualified status of a domestic relations order or a medical child support order, you may file suit in federal court.
If it should happen that plan fiduciaries misuse the Plan'
s money or if you are discriminated against for asserting
your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court.
The court will decide who should pay court costs and legal fees. If you are successful, the court may order the
POP PLUS FSAS
PAGE 23
SPD (REV. 11/2010)
person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and
fees (for example, if it finds your claim is frivolous).
5. Assistance with Your Questions
If you have any questions about the Plan, you should contact the Plan Administrator. If you have any questions
about this statement or about your rights under ERISA, or if you need assistance obtaining documents from the
Plan Administrator, you should contact the nearest office of the U.S. Department of Labor, Employee Benefits
Security Administration listed in your telephone directory, or the Division of Technical Assistance and
Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Ave., N.W.,
Washington, D.C., 20210. You may also obtain certain publications about your rights and responsibilities under
ERISA by calling the publications hotline of the Pension and Welfare Benefits Administration.
POP PLUS FSAS
PAGE 24
SPD (REV. 11/2010)
Part 9. Plan Information Summary
1. Employer Organization
Name of Organization:
Federal Employer ID Number:
22-3532457
Date Organized:
November 1, 1997
Mailing Address:
100 Metroplex Dr., Ste. 102
City, State, Zip:
Edison, NJ 08817
Form of Organization:
Limited Liability Company
Organized in the state of:
NJ
Affiliated Employers:
Power Optech, LLC
TGS Healthcare
2. Plan Elections
Plan Number:
501
Plan Name:
Tekmark Global Solutions, LLC Cafeteria Plan
Original Effective Date:
February 1, 1998
Plan Year Runs*:
April 1 – March 31
Plan Restated and Amended:
April 1, 2012
*This Plan is designed to run on a 12-month plan year period as stated above. A Short Plan Year may occur when the Plan is
first established, when the plan year period changes, or at the termination of a Plan.
Plan Administrator:
Plan Service Provider:
Street Address:
City, State, Zip:
Phone:
717-766-8844 or 1-888-273-7036
Benefits Coordinator
Name:
Charles K. Miller, III
Title:
COO
Phone:
732-572-5400
Company Name:
Street Address:
City, State, Zip:
Edison, NJ 08817
Acceptance of Legal Process
Name:
Charles K. Miller, III
Title:
COO
Phone:
732-572-9600
Company Name:
Street Address:
City, State, Zip:
Edison, NJ 08817
The appointed Plan Service Provider in conjunction with the Administrator will perform the functions of accounting, record
keeping, changes of participant family status, and any election or reporting requirements of the Internal Revenue Code.
3. Eligibility Requirements
a)
Except as provided in (b) below, the Classification of Eligible Employees consists of two separate classes:
Class I – Hourly Employees
POP PLUS FSAS
PAGE 25
SPD (REV. 11/2010)
Class II – Salaried Employees
b)
Employees excluded from this classification group are those individual employees who fall into one or more of the
following categories below:
Seasonal employees who normally work less than 6 months per year.
Part-time employees normally expected to work less than 30 hours per week.
Employees under the age of 18.
Union members, unless the bargaining agreement provides for coverage.
Service Period Requirement
Service period requirement means that employees must be in service or on the job to be eligible. The service period
requirement will be satisfied as of the date of hire.
4. Plan Entry Date
The Plan Entry Date is the date when an employee who has satisfied the Eligibility Requirements may commence
participation in the Plan. The Plan Entry Date is the later of the date the Employee files a Salary Reduction Agreement during
the applicable Enrollment Period or the first day of the month following the employee’s hire date.
5. Benefit Package Options
The following Benefit Package Options are offered under this Plan:
Core Health Plan
Dental Insurance Plan
Health FSA
Limited Purpose Health FSA
Dependent Care FSA
Health Savings Account
6. Flexible Spending Account Elections
The Closing Period is the period of time that begins after the Plan Year ends during which the employee can submit claims
for payment of Qualified Expenses incurred during the Plan Year. This Closing Period begins at the end of the Plan year and
terminates 90 days after the end of the plan year.
The Claims Submission Grace Period is the period of time after an employee terminates employment (or loses eligibility to
participate in the Plan) during which the employee can submit claims for expenses incurred while the employee remained a
participant. The Claim Submission Grace Period begins on the employee’s termination and ends 60 days after the date of
termination.
Amounts contributed for reimbursement benefits are segregated for record keeping and accounting purposes only, and this
process does not constitute a separate fund or entity as the reimbursements are made from the general assets of the plan
sponsor.
Health FSA
(a)
The maximum annual reimbursement amount an Employee may elect for any Plan Year is $2,500.
(b)
The maximum annual reimbursement amount that a Participant may receive during the year is the annual
reimbursement amount elected by the Employee on the Salary Reduction Agreement for Health FSA coverage, not to
exceed the amount set forth in (a) above.
(c)
Minimum Contribution for this Benefit per Plan Year per Employee is $200.
(d)
In order to receive reimbursement under the Health FSA, the claim or claims must equal or exceed the Minimum
Check Amount. If a claim or claims submitted by the Participant do not equal or exceed this amount, the claim or
claims will be held until the accumulated claims equal or exceed the Minimum Check Amount, except that claims
submitted for reimbursement during the last month of the Plan Year or during the Closing Period or Claims
Submission Grace Period, whichever is applicable, will not be subject to the Minimum Check Amount. The Minimum
Check Amount under this Plan is hereby set as $25.
POP PLUS FSAS
PAGE 26
SPD (REV. 11/2010)
Employer Funded Co-Insurance
For HSA Option 1
(MERP™ Plan)
S UMMARY P LAN D ESCRIPTION
AS ADOPTED BY:
TEKMARK GLOBAL SOLUTIONS, LLC
EFFECTIVE 04/01/2008, AMENDED AND RESTATED 04/01/2013
TABLE OF CONTENTS
INTRODUCTION.......................................................................................................................................... 1
PART I: QUESTIONS AND ANSWERS .................................................................................................... 1
Q-1.
What is the purpose of the Plan? ................................................................................................... 1
Q-2.
When did the Plan take effect?...................................................................................................... 1
Q-3.
Who can participate in the Tekmark Global Solutions, LLC MERP™ Plan? .............................. 1
Q-4.
What amount of eligible medical expenses may be reimbursed by Tekmark Global
Solutions, LLC MERP™ Plan each Year? ................................................................................... 1
Q-5.
What is an Eligible Medical Expense? .......................................................................................... 1
Q-6.
How do I receive Benefits under the Plan? ................................................................................... 1
Q-7.
When must the expenses be incurred for which I may be reimbursed? ........................................ 2
Q-8.
Does the plan also provide benefits for my family? ...................................................................... 2
Q-9.
What happens if my claim for benefits is denied? ........................................................................ 2
Q-10.
Does my coverage under this Plan end when my employment terminates?.................................. 3
Q-11.
What is Continuation Coverage and how does it work? ............................................................... 3
Q-12.
How long will the Plan remain in effect? ...................................................................................... 4
Q-13.
Will my health information be kept confidential? ......................................................................... 4
PART II: ERISA RIGHTS .......................................................................................................................... 5
PART III: GENERAL INFORMATION ABOUT OUR PLAN ............................................................... 7
1.
General Plan Information .............................................................................................................. 7
2.
Employer Information ................................................................................................................... 7
3.
Plan Administrator ........................................................................................................................ 7
4.
Service of Legal Process ............................................................................................................... 7
5.
MERP
Plan Service Provider .................................................................................................... 7
MERP™ Plan - Summary Plan Description
TEKMARK GLOBAL SOLUTIONS, LLC MERP™ PLAN
SUMMARY PLAN DESCRIPTION
INTRODUCTION
Tekmark Global Solutions, LLC (the "Employer") has established a plan known as the "Plan" or the “Tekmark Global Solutions, LLC
MERP™ Plan”. Tekmark Global Solutions, LLC MERP™ Plan is designed to reimburse eligible employees (those that are
participating in the Employer’s Insured Health Plan) for a portion of their and their dependents’ health claims that count toward the
co-insurance under Employer Insured Health Plan.
This Summary Plan Description describes the basic features of the Plan, how it operates, and how you can get the maximum
advantage from it. This is only a summary of the key parts of the Plan, and a brief description of your rights as a participant. It is not a
part of the official plan documents. If there is a conflict between the plan documents and this summary, the plan documents will apply.
PART I:
QUESTIONS AND ANSWERS
Q-1.
What is the purpose of the Plan?
The purpose of the Plan is to reimburse employees covered under the Plan for a portion of the medical expenses they incur
each year, which count toward the in network co-insurance under the Employer’s Insured Health Plan while they are
employed with the Employer and the Plan remains in effect.
Q-2.
When did the Plan take effect?
The Plan became effective on 04/01/2008, amended and restated 04/01/2013.
Q-3.
Who can participate in the Tekmark Global Solutions, LLC MERP™ Plan?
Each full-time employee of the Employer who is eligible to participate in the Employer’s Insured Health Plan is eligible to
participate in the Tekmark Global Solutions, LLC MERP™ Plan if insured under the HSA Option 1 plan. Participation in the
Tekmark Global Solutions, LLC MERP™ Plan is automatic upon the employee’s Participation in the Employer’s Insured
Health Plan HSA Option 1. Participation in Tekmark Global Solutions, LLC MERP™ Plan shall terminate on the earliest of:
i) the date an Employee ceases to be an Employee; ii) when an Employee ceases to meet the eligibility requirements of this
Plan (e.g., the Employee loses coverage under the Insured Health Plan by failing to pay any applicable premium); and iii) the
date this Plan is amended to exclude the Employee or is terminated.
Q-4.
What amount of eligible medical expenses may be reimbursed by Tekmark Global Solutions, LLC
MERP™ Plan each Plan Year?
The plan’s plan year benefits only pertain to In Network co-insurance benefits received and per person and per family
maximums are determined as follows: Eligible claims are those that have been applied to the employee’s individual and/or
family’s In Network Co-Insurance as identified on the Explanation of Benefits (EOB).
The employer shall reimburse eligible expenses at a rate of 100% not to exceed $3,000 Single and $6,000 Family of In Network coinsurance and RX copays incurred after the deductible has been satisfied per plan year.
Q-5.
What is an Eligible Medical Expense?
Eligible Medical Expenses are those expenses incurred by the Employee, or the Employee's Dependents, after the date of the
Employee's participation in the Employer’s Insured Health Plan and simultaneously in Tekmark Global Solutions, LLC
MERP™ Plan and during the Plan Year otherwise allowable as deductions under Code Sec. 213 (without regard to the
limitations contained in Sec. 213(a)) that are covered expenses which count toward the satisfaction of the Employee's annual
in-network co-insurance, as noted in Q-4 above. Once the employers maximum annual payment of the above referenced Q-4
per person and per person w/ dependents “In Network” and amounts in the Insured Health Plan is exceeded, medical
expenses become fully reimbursable under Insured Health Plan, and no further Benefits shall be payable under the Tekmark
Global Solutions, LLC MERP™ Plan. For purposes of this Plan, an expense is "incurred" when the Participant or beneficiary
is furnished the medical care or services giving rise to the claimed expense.
REV. 12/12/07
1
Q-6.
How do I receive Benefits under the Plan?
To have your claims processed as soon as possible, you will need to complete a “Request for Reimbursement Claim Form”
(provided by your employer), enclose a copy of your Explanation of Benefits (EOB) form and mail to: Benefit Design
Specialists, Inc., 600 Wilson Ln., Ste 200, Mechanicsburg, PA 17055. Faxes are also acceptable if legible and may be faxed
to 855-296-1027. A supply of self addressed envelopes and claim forms are available through your HR department.
Your employer has contracted with Benefit Design Specialists, Inc. to process the claims on its behalf. Please note that it is
not necessary that you have actually paid an amount due for Eligible Medical Expense -- only that you have incurred the
expense, that you have submitted it to, that it has been processed and reported by your insurer via the EOB, and that it is not
being paid for or reimbursed from any other source.
The Closing Period is the period of time that begins after the Plan Year ends during which the employee can submit claims
incurred during the Plan Year. Claims (EOBs) can be submitted up to sixty (60) days after the close of the Plan Year. Any
claims received after sixty (60) days of the close of the plan will not be eligible for reimbursement.
Q-7.
When must the expenses be incurred for which I may be reimbursed?
Eligible Expenses must have been incurred during the Plan Year. You may not be reimbursed for any expenses arising before
the Plan became effective, before you became covered under the Plan, simultaneous to the time you became covered under
your Employer’s Insured Health Plan, or for any expenses incurred after the close of the Plan Year, or, except for
Continuation Coverage, after a separation from service.
Q-8.
Does the plan also provide benefits for my family?
The Plan provides reimbursement for Eligible Medical Expenses incurred by your dependents who meet the following
conditions: any individual who is (a) your legal spouse, a tax dependent defined under Code Section 152 (except that a child
of divorced parents is considered a dependent of both parents), or any child for whom you are required to provide health
coverage pursuant to a Qualified Medical Child Support Order and (b) covered as a dependent under the Group Health Plan.
Q-9.
What happens if my claim for benefits is denied?
If you are denied a benefit under the Plan, you should proceed in accordance with the following claims review procedures.
Step 1: Notice is received from Plan Service Provider. If your claim is denied, you will receive written notice from the Plan
Service Provider that your claim is denied as soon as reasonably possible but no later than 30 days after receipt of the claim.
For reasons beyond the control of the Plan Service Provider, the Plan Service Provider may take up to an additional 15 days
to review your claim. You will be provided written notice of the need for additional time prior to the end of the 30-day
period. If the reason for the additional time is that you need to provide additional information, you will have 45 days from the
notice of the extension to obtain that information. The time period during which the Plan Service Provider must make a
decision will be suspended until the earlier of the date that you provide the information or the end of the 45-day period.
Step 2: Review your notice carefully. Once you have received your notice from the Plan Service Provider, review it
carefully. The notice will contain:
reason(s) for the denial and the Plan provisions on which the denial is based;
description of any additional information necessary for you to perfect your claim, why the information is necessary,
description of the Plan’s appeal procedures and the time limits applicable to such procedures;
right to request all documentation relevant to your claim;
Step 3: If you disagree with the decision, file an Appeal. If you do not agree with the decision of the Plan Service Provider,
you may file a written appeal. You should file your appeal no later than 180 days of receipt of the notice described in Step 1.
If the Plan has established only one level of review, you should file your appeal with the Plan Administrator. If the Plan has
established two levels of appeal, you should file your appeal with the Plan Service Provider. The notice of denial reference in
Step 1 above will indicate whether the plan has 1 or 2 levels of appeal. Regardless, you should submit all information
identified in the notice of denial as necessary to perfect your claim and any additional information that you believe would
support your claim.
Step 4: Notice of Denial is received from claims reviewer. If the claim is again denied, you will be notified in writing. If the
plan has established two levels of appeal as set forth in the notice of denial, the notice will be sent no later than 30 days after
REV. 12/12/07
2
receipt of the appeal by the Plan Service Provider. Otherwise, notice of the denial will be sent no later than 60 days after the
appeal is received by the Plan Administrator.
Step 5: Review your notice carefully. You should take the same action that you take in Step 2 described above. The notice
will contain the same type of information that is provided in the first notice of denial provided by the Plan Service Provider.
Step 6 (if there is a second level of appeal as indicated in the notice of denial): If you still disagree with the Plan Service
Provider’s decision, file a 2nd Level Appeal with the Plan Administrator. If you still do not agree with the Plan Service
Provider’s decision, you may file a written appeal with the Plan Administrator within allotted number of days set forth in the
notice of denial from the Plan Service Provider. You should gather any additional information that is identified in the notice
as necessary to perfect your claim and any other information that you believe would support your claim.
If the Plan Administrator denies your 2nd Level Appeal, you will receive notice within 30 days after the Plan Administrator
receives your claim. The notice will contain the same type of information that was referenced in Step 2 above.
Important Information
Other important information regarding your appeals:
Each level of appeal will be independent from the previous level (i.e. the same person(s) or subordinates of the
same person(s) involved in a prior level of appeal will not be involved in the appeal);
On each level of appeal, the claims reviewer will review relevant information that you submit even if it is new
information;
You cannot file suit in federal court until you have exhausted these appeals procedures.
Q-10. Does my coverage under this Plan end when my employment terminates?
Yes. Your normal participation will cease at the end of the last day that your employment with the Employer terminates.
However, you and your family will have the opportunity to continue to be covered under the Plan under the terms of the
Continuation Coverage provisions described in Answer Q-11, below.
The Claims Submission Grace Period is the period of time after an employee terminates employment (or loses eligibility to
participate in the Plan) during which the employee can submit claims for expenses incurred while the employee remained a
participant. The Claim Submission Grace Period begins on the employee’s termination date and ends 60 days after the date of
termination.
Q-11. What is "Continuation Coverage" and how does it work?
Federal law requires most employers sponsoring group health plans to offer employees and their families the opportunity for
a temporary extension of health care coverage (called “continuation coverage”) at group rates in certain instances where
coverage under the plans would otherwise end. These rules apply to the MERP Plan, unless the Employer is a smallemployer within the meaning of the applicable regulations. The Plan Administrator can tell you whether the Employer is a
small employer (and thus not subject to these rules).
If you are a participant in the MERP
you lose your coverage because of:
Plan, then you have a right to choose continuation coverage under the MERP
Plan if
a reduction in your hours of employment;
a voluntary or involuntary termination of your employment (for reasons other than gross misconduct), or
a military leave of absence that lasts 31 days or longer (in accordance with USERRA).
If you are the spouse of a Participant, then you have the right to choose continuation coverage for yourself if you lose
coverage for any of the following reasons:
the death of your spouse;
a voluntary or involuntary termination of your spouse's employment (for reasons other than gross misconduct) or
reduction in your spouse's hours of employment; or
the divorce or legal separation from your spouse;
In the case of a Dependent child of a participant, he or she has the right to choose continuation coverage if coverage is lost for
any of the following reasons:
the death of the employee;
REV. 12/12/07
3
a voluntary or involuntary termination of the employee's employment (for reasons other than gross misconduct) or
reduction in the employee's hours of employment;
his or her parents' divorce or legal separation; or
he or she ceases to be a dependent child.
A child who is born to, or placed for adoption with, the employee during a period of continuation coverage is also entitled to
continuation coverage under COBRA. Those who are entitled to continue coverage under COBRA are called “Qualified
Beneficiaries”
If you choose continuation coverage, you may continue the level of coverage you had in effect immediately preceding the
qualifying event. However, if Plan benefits are modified for similarly situated active employees, then they will be modified
for you and other Qualified Beneficiaries as well. You will be eligible to make a change in your benefit election with respect
to the Plan upon the occurrence of any event that permits a similarly situated active employee to make a benefit election
change during a Plan Year.
If you do not choose continuation coverage, your coverage under the MERP
otherwise lose coverage.
Plan will end with the date you would
You or your covered dependents (including your spouse) must notify the employer of a divorce, legal separation, or a child
losing dependent status under the Plan within 60 days of the later of the date of the event or the date on which coverage is
lost because of the event. When the Plan Administrator (or its COBRA Administrator identified in the Plan Information
Appendix) is notified that one of these events has occurred, the Plan Administrator will in turn notify you that you have the
right to choose continuation coverage. Notice to an employee's spouse is treated as notice to any covered Dependents who
reside with the spouse.
An employee or covered dependent is responsible for notifying the Plan Administrator if he or she becomes covered under
another group health plan.
Each qualified beneficiary is entitled to make a separate election for continuation coverage under the Plan. In order to elect
continuation coverage, you must complete the election form(s) provided to you by the Plan Administrator. You have 60 days
from the date you would lose coverage for one of the reasons described above or the date you are sent notice of your right to
elect continuation coverage, whichever is later, to inform the Plan Administrator that you wish to continue coverage. Failure
to return the election form within the 60-day period will be considered a waiver, and you will not be allowed to elect
continuation coverage.
You will have to pay the entire cost of your continuation coverage. The cost of your continuation coverage will not exceed
102% of the applicable premium for the period of continuation coverage. The first premium payment after electing
continuation coverage will be due 45 days after making your election. Subsequent premiums must be paid within a 30-day
grace period following the due date. Failure to pay premiums within this time period will result in automatic termination of
your continuation coverage. Claims incurred during any period will not be paid until your premium payment is received for
that period. If you timely elect continuation coverage and pay the applicable premium, however, then continuation coverage
will relate back to the first day on which you would have lost regular coverage.
To the extent that Nonelective Employer contributions are provided, the maximum duration of coverage may be 18 or 36
months from the qualifying event (depending on the type of qualifying event). You will be notified of the duration of
continuation coverage when you have a qualifying event. However, continuation coverage may end earlier for any of the
following reasons:
The contribution for your continuation coverage is not paid on time or it is insufficient (Note if your payment is
insufficient by the lesser of 10% of the required COBRA premium, or $50, you will be given 30 days to cure the
shortfall);
The date that you first become covered under another group health plan under which you are not subject to a preexisting condition exclusion limitation, after you elect continuation coverage;
The date that you first become entitled to Medicare, after you elect continuation coverage; or
The date employer no longer provides group health coverage to any of its employees
REV. 12/12/07
4
Q-12. How long will the Plan remain in effect?
Although the Employer expects to maintain the Plan indefinitely, it has the right to modify or terminate the program at any
time.
Q-13. Will my health information be kept confidential?
Under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) group health plans such as the Medical
Expense Reimbursement Plan and the third party service providers are required to take steps to ensure that certain “protected
health information is kept confidential. You may receive a separate notice that outlines the health privacy policies of the Plan.
PART II:
ERISA RIGHTS
As a Participant in the Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act
("ERISA"). ERISA provides that all plan participants shall be entitled to:
1. Receive Information about Your Plan and Benefits
Examine, without charge, at the Plan Administrator's office and at other specified locations, such as worksites and
union halls, all documents governing the plan, including insurance contracts, collective bargaining agreements, and a copy of
the latest annual report (Form 5500 series) (if any) filed by the Plan with the U.S. Department of Labor and available at the
Public Disclosure Room of the Pension and Welfare Benefit Administration.
Obtain, upon written request to the plan administrator, copies of all documents governing the operation of the plan,
including insurance contracts and collective bargaining agreement, and copies of the latest annual report (Form 5500 series)
(if any) and updated Summary Plan Description. The Plan Administrator may make a reasonable charge for the copies.
Receive a summary of the Plan's annual financial report. The Plan Administrator is required by law to furnish each
participant with a copy of this summary annual report.
2.
Continue Group Health Plan Coverage
Continue health coverage for you, your spouse, or your dependents if there is a loss of coverage under the plan as a
result of a qualifying event. However, you or your dependents may have to pay for such coverage. Review this Summary
Plan Description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights.
Obtain reduction or elimination of exclusionary periods of coverage for preexisting conditions under your group
health plan, if you have creditable coverage under another plan. You should be provided a certificate of creditable coverage,
free of charge, from your group health plan or health insurance issuer when you lose coverage under the Plan, when you
become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases (if you requested
continuation coverage), before losing coverage (if you requested continuation coverage), or up to 24 months after losing
coverage (if you requested continuation coverage). Without evidence of creditable coverage, you may be subject to
preexisting condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage.
3.
Prudent Actions by Plan Fiduciaries
4.
In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation
of the Employee Benefit Plan. The people who operate your Plan, called "fiduciaries" of the Plan, have a duty to do so prudently
and in the interest of the Plan participants and beneficiaries. No one, including your employer, your union, or any other person,
may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit from the Plan, or
from exercising your rights under ERISA.
Enforcement of Your Rights
If your claim for a welfare benefit under an ERISA-covered plan is denied in whole or in part, you must receive a written
explanation of the reason for the denial. You have the right to have the Plan review and reconsider your claim. Under ERISA,
there are steps you can take to enforce the above rights. For instance, if you request materials from the Plan and do not receive
them within 30 days, you may file suit in a federal court. In such a case, the court may require the Plan Administrator to provide
the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons
beyond the control of the Administrator. If you have a claim for benefits, which is denied or ignored in whole or in part, you may
file suit in a state or federal court. In addition, if you disagree with the plan’s decision or lack thereof concerning the qualified
status of a domestic relations order or a medical child support order, you may file suit in federal court. If it should happen that
plan fiduciaries misuse the Plan's money or if you are discriminated against for asserting your rights, you may seek assistance
from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and
REV. 12/12/07
5
5.
legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court
may order you to pay these costs and fees (for example, if it finds your claim is frivolous).
Assistance with Your Questions
6.
If you have any questions about the Plan, you should contact the Plan Administrator. If you have any questions about this
statement or about your rights under ERISA, or if you need assistance obtaining documents from the Plan Administrator, you
should contact the nearest office of the U.S. Department of Labor, Employee Benefits Security Administration listed in your
telephone directory, or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S.
Department of Labor, 200 Constitution Ave., N.W., Washington, D.C., 20210. You may also obtain certain publications about
your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security
Administration.
Claims Procedure
A Participant, or a Participant through his or her authorized representative, may make a claim, or appeal a denial of a claim,
under this claims procedure.
a. Post-Service. For post-service claims, the Plan representative shall respond within 30 days after receipt of the claim, and
this time period may be extended up to 15 days due to matters beyond the control of the representative, in which case the
Participant shall be notified of the need for extension and the reasons therefore. If the Participant fails to provide
information needed to process this type of claim, an additional 45 days shall be granted to provide the information.
b. Denial of a Claim. A denial of a claim shall provide specific detailed information to the Participant. The denial shall
provide the specific reason or reasons for the denial, a reference to the specific Plan provisions on which the denial is based,
a description of any additional material information that might be needed to complete a claim, if the claim is incomplete, and
an explanation why that material information is necessary, a description of the Plan's review procedure and time limits
applicable for an appeal, and, if there is an internal rule, guideline, protocol, or criteria used to determine approval or denial
of the particular type of claim, the Participant shall be offered a copy of the rule, guideline, protocol, or other criterion free
of charge upon request. Furthermore, if the denial of a claim is based upon a determination of medical necessity,
experimental treatment or similar exclusion or limit, then an explanation of the scientific or clinical judgment involved in
such a determination, applying the terms of the Plan to the Participant's medical circumstances, shall be provided to the
Participant free of charge upon request.
c. Appeal Process. Any denial of a claim may be appealed by the Participant. The plan shall provide a full and fair review
process. The Participant shall have the opportunity to submit written comments, documents, records, and other information
related to the claim, and will be provided upon request, and free of charge, reasonable access to documents, records and
other information that are relevant to the claim. The review shall take into account any new information submitted by the
Participant whether or not such information was available for the initial denial of the claim. A document, record or other
information shall be provided to the Participant, upon request and free of charge, if it was relied upon in denying the claim,
or was submitted, considered, or generated in the course of determining whether or not to deny a claim, or constitutes a
statement of policy or guidance with respect to a treatment option, benefit, or diagnosis.
The Participant shall have at least 180 days following denial of a claim to appeal the determination. The appeal shall be
determined by a specified individual or committee who is not the same individual or committee who denied the claim, nor is the
subordinate of the individual denying the claim. If the decision on appeal is required to be based in whole or in part on a medical
judgment, such as whether or not a treatment or drug or item is experimental, investigational, or not medically necessary or
appropriate, the person or persons determining the appeal shall consult with a health care professional who has training and
experience in the field of medicine involved. The decision on appeal will identify the medical experts whose advice was
obtained in determining that the appeal was to be denied, and the health care professional involved in determining the appeal
shall not be the same individual who was involved in the denial of the claim or any subordinate of such individual.
For post-service claims, the determination on appeal shall be provided within 60 days after receipt of the request for review,
but for two levels of review, the second level review determination shall be made within 30 days after receipt of request for
review.
Any denial of an appeal shall include the specific reason or reasons for the denial, reference to the specific Plan provisions on
which denial is based, and the statement that the Participant is entitled to receive, free of charge, documents, records or other
information relevant to the claim for benefits including copies of any internal rule, guideline, protocol or similar criteria used to
make the determination, and a copy of the statement of the scientific or clinical judgment utilized to determine medical necessity
or experimental treatment, or other applicable similar exclusion or limit, if it was applied in the Participant's case. 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 local U.S. Department of Labor office or your state insurance regulatory agency.
REV. 12/12/07
6
PART III:
GENERAL INFORMATION ABOUT OUR PLAN
This Section contains certain general information that you may need to know about the Plan.
1.
General Plan Information
Tekmark Global Solutions, LLC has established a plan for payment of certain expenses for the benefit of its eligible
employees to be named and known as the Tekmark Global Solutions, LLC MERP Plan.
Your Employer has assigned Plan Number 501 to your Plan.
The provisions of the Plan described herein became effective on 04/01/2008, amended and restated 04/01/2013.
Your Plan's records are maintained on a twelve-month period of time. This is known as the Plan Year. The first Plan Year
began on 04/01/2008, amended and restated 04/01/2013 and will end on 03/31/2014.
2.
Employer Information
Your Employer's name and address are:
100 Metroplex Dr.
Edison, NJ 08817
3.
Plan Administrator Information
The name, address, and business telephone number of your Plan's Administrator are:
Attention: Charles K. Miller, III COO
100 Metroplex Dr.
Edison, NJ 08817
732-572-5400
The Administrator appoints a Committee, which keeps the records for the Plan and is responsible for the administration of the
Plan. The Committee will also answer any questions you may have about our Plan. You may contact the Committee at the
above address for any further information about the Plan.
4.
Service of Legal Process
The name and address of the Plan's agent for service of legal process is:
100 Metroplex Dr.
Edison, NJ 08817
732-572-5400
5.
MERP™ Plan Service Provider
600 Wilson Ln., Ste. 200
Phone: 888-273-7036
FAX: 855-296-1027
REV. 12/12/07
7
UnitedHealthcare Choice Plus
UnitedHealthcare Insurance Company
Certificate of Coverage
For
the Plan NHZ
of
Tekmark Global Solutions LLC
Enrolling Group Number: 709590
Effective Date: April 1, 2013
Offered and Underwritten by
Table of Contents
Schedule of Benefits ...................................................................................1
Accessing Benefits............................................................................................................................... 1
Prior Authorization ............................................................................................................................... 1
Covered Health Services which Require Prior Authorization ................................................................. 2
Care Management ............................................................................................................................... 3
Special Note Regarding Medicare........................................................................................................ 3
Benefits ............................................................................................................................................... 4
Eligible Expenses .............................................................................................................................. 24
Provider Network ............................................................................................................................... 25
Continuation of Treatment when a Physician Leaves the Network ...................................................... 26
Designated Facilities and Other Providers.......................................................................................... 26
Health Services from Non-Network Providers Paid as Network Benefits ............................................. 27
Limitations on Selection of Providers.................................................................................................. 27
Certificate of Coverage ...............................................................................1
Certificate of Coverage is Part of Policy ............................................................................................... 1
Changes to the Document.................................................................................................................... 1
Other Information You Should Have..................................................................................................... 1
Introduction to Your Certificate .................................................................2
How to Use this Document................................................................................................................... 2
Information about Defined Terms ......................................................................................................... 2
Don't Hesitate to Contact Us ................................................................................................................ 2
Your Responsibilities ..................................................................................3
Be Enrolled and Pay Required Contributions........................................................................................ 3
Be Aware this Benefit Plan Does Not Pay for All Health Services ......................................................... 3
Decide What Services You Should Receive ......................................................................................... 3
Choose Your Physician........................................................................................................................ 3
Obtain Prior Authorization .................................................................................................................... 3
Pay Your Share ................................................................................................................................... 3
Pay the Cost of Excluded Services....................................................................................................... 4
Show Your ID Card .............................................................................................................................. 4
File Claims with Complete and Accurate Information ............................................................................ 4
Use Your Prior Health Care Coverage.................................................................................................. 4
Our Responsibilities....................................................................................5
Determine Benefits .............................................................................................................................. 5
Pay for Our Portion of the Cost of Covered Health Services ................................................................. 5
Pay Network Providers......................................................................................................................... 5
Pay for Covered Health Services Provided by Non-Network Providers ................................................. 5
Review and Determine Benefits in Accordance with our Reimbursement Policies................................. 5
Offer Health Education Services to You ............................................................................................... 6
Certificate of Coverage Table of Contents ...............................................7
Section 1: Covered Health Services ..........................................................8
Benefits for Covered Health Services................................................................................................... 8
1. Ambulance Services ........................................................................................................................ 8
2. Autism Spectrum Disorder and Other Developmental Disabilities – Rehabilitative Services .............. 9
3. Clinical Trials ................................................................................................................................... 9
4. Congenital Heart Disease Surgeries............................................................................................... 10
5. Dental Services - Accident Only ..................................................................................................... 11
6. Dental Services - Other.................................................................................................................. 11
7. Diabetes Services .......................................................................................................................... 12
8. Durable Medical Equipment ........................................................................................................... 13
i
9. Emergency Health Services - Outpatient ........................................................................................ 14
10. Hearing Aids ................................................................................................................................ 14
11. Hearing Loss Screening ............................................................................................................... 14
12. Hemophilia Services .................................................................................................................... 14
13. Home Health Care ....................................................................................................................... 14
14. Hospice Care ............................................................................................................................... 15
15. Hospital - Inpatient Stay ............................................................................................................... 15
16. Infertility Services......................................................................................................................... 16
17. Lab, X-Ray and Diagnostics - Outpatient ...................................................................................... 17
18. Lab, X-Ray & Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient 17
19. Medical Foods.............................................................................................................................. 17
20. Mental Health Services ................................................................................................................ 17
21. Neurobiological Disorders - Autism Spectrum Disorder Services .................................................. 18
22. New Jersey Early Intervention Family Cost Share Expense .......................................................... 19
23. Ostomy Supplies.......................................................................................................................... 19
24. Pharmaceutical Products - Outpatient .......................................................................................... 20
25. Physician Fees for Surgical and Medical Services ........................................................................ 20
26. Physician's Office Services - Sickness and Injury ......................................................................... 21
27. Pregnancy - Maternity Services.................................................................................................... 21
28. Preventive Care Services............................................................................................................. 21
29. Prosthetic and Orthotic Devices ................................................................................................... 23
30. Reconstructive Procedures .......................................................................................................... 23
31. Rehabilitation Services - Outpatient Therapy and Manipulative Treatment .................................... 24
32. Scopic Procedures - Outpatient Diagnostic and Therapeutic......................................................... 24
33. Skilled Nursing Facility/Inpatient Rehabilitation Facility Services................................................... 25
34. Specialized Non-Standard Infant Formulas................................................................................... 25
35. Substance Use Disorder Services ................................................................................................ 26
36. Surgery - Outpatient..................................................................................................................... 27
37. Therapeutic Treatments - Outpatient ............................................................................................ 27
38. Transplantation Services.............................................................................................................. 27
39. Urgent Care Center Services........................................................................................................ 28
40. Vision Examinations..................................................................................................................... 28
Section 2: Exclusions and Limitations....................................................29
How We Use Headings in this Section ............................................................................................... 29
We do not Pay Benefits for Exclusions ............................................................................................... 29
Benefit Limitations.............................................................................................................................. 29
A. Alternative Treatments................................................................................................................... 29
B. Dental............................................................................................................................................ 29
C. Devices, Appliances and Prosthetics ............................................................................................. 30
D. Drugs ............................................................................................................................................ 31
E. Experimental or Investigational or Unproven Services.................................................................... 31
F. Foot Care ...................................................................................................................................... 31
G. Medical Supplies ........................................................................................................................... 32
H. Mental Health ................................................................................................................................ 32
I. Neurobiological Disorders - Autism Spectrum Disorders.................................................................. 33
J. Nutrition ......................................................................................................................................... 34
K. Personal Care, Comfort or Convenience........................................................................................ 34
L. Physical Appearance ..................................................................................................................... 35
M. Procedures and Treatments .......................................................................................................... 36
N. Providers....................................................................................................................................... 37
O. Reproduction................................................................................................................................. 37
P. Services Provided under another Plan ........................................................................................... 37
Q. Substance Use Disorders.............................................................................................................. 38
R. Transplants ................................................................................................................................... 38
S. Travel ............................................................................................................................................ 39
ii
T. Types of Care ................................................................................................................................ 39
U. Vision and Hearing ........................................................................................................................ 39
V. All Other Exclusions....................................................................................................................... 40
Section 3: When Coverage Begins ..........................................................42
How to Enroll ..................................................................................................................................... 42
If You Are Hospitalized When Your Coverage Begins......................................................................... 42
Who is Eligible for Coverage .............................................................................................................. 42
Eligible Person................................................................................................................................... 42
Dependent ......................................................................................................................................... 42
When to Enroll and When Coverage Begins....................................................................................... 43
Initial Enrollment Period ..................................................................................................................... 43
Open Enrollment Period..................................................................................................................... 43
Dependent Child Special Open Enrollment Period.............................................................................. 43
New Eligible Persons ......................................................................................................................... 43
Adding New Dependents ................................................................................................................... 43
Special Enrollment Period.................................................................................................................. 44
Section 4: When Coverage Ends .............................................................46
General Information about When Coverage Ends............................................................................... 46
Events Ending Your Coverage ........................................................................................................... 46
Other Events Ending Your Coverage.................................................................................................. 47
Coverage for a Disabled Dependent Child.......................................................................................... 47
Extended Coverage for Total Disability............................................................................................... 47
Continuation of Coverage and Conversion ......................................................................................... 48
Continuation Coverage under Federal Law (COBRA)......................................................................... 48
Qualifying Events for Continuation Coverage under Federal Law (COBRA)........................................ 48
Notification Requirements and Election Period for Continuation Coverage under Federal Law (COBRA)
.......................................................................................................................................................... 49
Terminating Events for Continuation Coverage under Federal Law (COBRA)..................................... 49
New Jersey Continuation Rights for Over-Age Dependents (NJCROD) .............................................. 50
State Continuation of Coverage for Totally Disabled Subscribers ....................................................... 53
Optional State Continuation of Coverage After the Subscriber's Death ............................................... 53
Conversion ........................................................................................................................................ 53
Section 5: How to File a Claim .................................................................55
If You Receive Covered Health Services from a Network Provider...................................................... 55
If You Receive Covered Health Services from a Non-Network Provider .............................................. 55
Required Information ......................................................................................................................... 55
Payment of Benefits........................................................................................................................... 56
Section 6: Questions, Complaints and Appeals ....................................57
What to Do if You Have a Question.................................................................................................... 57
What to Do if You Have a Complaint .................................................................................................. 57
How to Appeal a Claim Decision ........................................................................................................ 57
Post-service Claims ........................................................................................................................... 57
Pre-service Requests for Benefits ...................................................................................................... 58
How to Request an Appeal................................................................................................................. 58
Appeal Process.................................................................................................................................. 58
Appeals Determinations ..................................................................................................................... 58
Pre-service Requests for Benefits and Post-service Claim Appeals .................................................... 58
Urgent Appeals that Require Immediate Action .................................................................................. 59
External Review Program................................................................................................................... 59
Section 7: Coordination of Benefits ........................................................60
Benefits When You Have Coverage under More than One Plan ......................................................... 60
When Coordination of Benefits Applies .............................................................................................. 60
Definitions.......................................................................................................................................... 60
Primary and Secondary Plan.............................................................................................................. 61
iii
Order of Benefit Determination Rules................................................................................................. 62
Effect on the Benefits of This Plan...................................................................................................... 63
Section 8: General Legal Provisions .......................................................65
Your Relationship with Us .................................................................................................................. 65
Our Relationship with Providers and Enrolling Groups........................................................................ 65
Your Relationship with Providers and Enrolling Groups ...................................................................... 66
Notice ................................................................................................................................................ 66
Statements by Enrolling Group or Subscriber ..................................................................................... 66
Incentives to Providers....................................................................................................................... 66
Incentives to You ............................................................................................................................... 67
Rebates and Other Payments ............................................................................................................ 67
Interpretation of Benefits .................................................................................................................... 67
Administrative Services...................................................................................................................... 67
Amendments to the Policy.................................................................................................................. 68
Information and Records.................................................................................................................... 68
Examination of Covered Persons ....................................................................................................... 69
Workers' Compensation not Affected ................................................................................................. 69
Refund of Overpayments ................................................................................................................... 69
Limitation of Action............................................................................................................................. 69
Entire Policy....................................................................................................................................... 70
Section 9: Defined Terms .........................................................................71
Amendments, Riders and Notices (As Applicable)
Oral Chemotherapeutic Agents Amendment
Health Resources and Services Administration (HRSA) Amendment
Outpatient Prescription Drug Rider
Oral Chemotherapeutic Agents Addendum
Important Notices under the Patient Protection and Affordable Care
Act (PPACA)
Changes in Federal Law that Impact Benefits
Women's Health and Cancer Rights Act of 1998
Statement of Rights under the Newborns' and Mothers' Health
Protection Act
Claims and Appeal Notice
Health Plan Notices of Privacy Practices
Financial Information Privacy Notice
Health Plan Notice of Privacy Practices: Federal and State
Amendments
Statement of Employee Retirement Income Security Act of 1974
(ERISA) Rights
ERISA Statement
iv
Schedule of Benefits
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. Emergency Health Services are always paid as Network Benefits. 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. Network Benefits 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.
Depending on the geographic area and the service you receive, you may have access through our
Shared Savings Program to non-Network providers who have agreed to discount their charges for
Covered Health Services. If you receive Covered Health Services from these providers, the Coinsurance
will remain the same as it is when you receive Covered Health Services from non-Network providers who
have not agreed to discount their charges; however, the total that you owe may be less when you receive
Covered Health Services from Shared Savings Program providers than from other non-Network providers
because the amount paid for Eligible Expenses may be a lesser amount.
You must show your identification card (ID card) or have your provider verify your eligibility by calling us
every time you request health care services from a Network provider. If you do not show your ID card or
have your provider verify your eligibility, 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. If you have not received your ID card from us, or if you have lost your ID card, please contact us
as soon as possible. If you need to seek services and do not have your ID card, please direct your
provider to verify your eligibility by calling us to ensure proper payment of claims.
Additional information about the network of providers and how your Benefits may be affected
appears at the end of this Schedule of Benefits.
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 prior authorization is required are identified below and in the Schedule of Benefits table within each
Covered Health Service category.
We recommend that you confirm with us that all Covered Health Services listed below have been prior
authorized as required. Before receiving these services from a Network provider, you may want to contact
us to verify that the Hospital, Physician and other providers are Network providers and that they have
SBN.CHP.I.11.NJ.R2
1
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.
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. Refer to the applicable Benefit description in
the Schedule of Benefits table to determine how far in advance you must obtain prior
authorization.

Ambulance - non-emergent air and ground.

Autism Spectrum Disorder and Other Developmental Disabilities - Rehabilitative Services.

Clinical trials.

Congenital heart disease surgery.

Dental services - accidental (for follow-up (post-Emergency) treatment).

Dental services - Other (for follow-up (post-Emergency) treatment).

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).

Genetic Testing, including BRCA Genetic Testing.

Hemophilia Services.

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.

Infertility services.

Medical Foods.

Mental Health Services - inpatient services (including Partial Hospitalization/Day Treatment and
services at a Residential Treatment Facility); Intensive Outpatient Treatment programs; outpatient
SBN.CHP.I.11.NJ.R2
2
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).

Reconstructive procedures, including breast reconstruction surgery following mastectomy.

Rehabilitation services and Manipulative Treatment - Manipulative Treatment.

Skilled Nursing Facility and Inpatient Rehabilitation Facility services.

Specialized Non-Standard Infant Formulas.

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: pain management procedures, diagnostic
catheterization and electrophysiology implant and sleep apnea surgeries.

Therapeutics - only for the following services: dialysis, intensity modulated radiation therapy and
MR-guided focused ultrasound.

Transplants.
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.
Special Note Regarding Medicare
If you are enrolled in Medicare on a primary basis (Medicare pays before we pay Benefits under the
Policy), the prior authorization requirements do not apply to you. Since Medicare is the primary payer, we
will pay as secondary payer as described in Section 7: Coordination of Benefits. You are not required to
obtain authorization before receiving Covered Health Services.
SBN.CHP.I.11.NJ.R2
3
Benefits
Annual Deductibles are calculated on a Policy year basis.
Out-of-Pocket Maximums are calculated on a Policy year basis.
When Benefit limits apply, the limit stated refers to any combination of Network Benefits and Non-Network
Benefits unless otherwise specifically stated.
Benefit limits are calculated on a Policy year basis unless otherwise specifically stated.
Payment Term And Description
Amounts
Annual Deductible
The amount of Eligible Expenses you pay for Covered Health
Services per year before you are eligible to receive Benefits.
When a Covered Person was previously covered under a
group policy that was replaced by the group Policy, any
amount already applied to that annual deductible provision of
the prior policy will apply to the Annual Deductible provision
under the Policy.
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. Details about the way in which Eligible Expenses
are determined appear at the end of the Schedule of Benefits
table.
Network
$2,500 per Covered Person, not to
exceed $5,000 for all Covered
Persons in a family.
Non-Network
The Annual Deductible does not apply to services provided by
capitated providers or to Non-Network lead poisoning
screenings for children.
Out-of-Pocket Maximum
The maximum you pay per year for the Annual Deductible,
Copayments or Coinsurance. Once you reach the Out-ofPocket Maximum, Benefits are payable at 100% of Eligible
Expenses during the rest of that year.
Details about the way in which Eligible Expenses are
determined appear at the end of the Schedule of Benefits
table.
The Out-of-Pocket Maximum does not include any of the
following and, once the Out-of-Pocket Maximum has been
reached, you still will be required to pay the following:
Network
The Out-of-Pocket Maximum includes
the Annual Deductible.
Non-Network

Any charges for non-Covered Health Services.

The amount Benefits are reduced if you do not obtain
prior authorization as required.

Charges that exceed Eligible Expenses.

Copayments or Coinsurance for any Covered Health
Service identified in the Schedule of Benefits table that
does not apply to the Out-of-Pocket Maximum.
SBN.CHP.I.11.NJ.R2
4

Amounts
Copayments or Coinsurance for Covered Health
Services provided under the Outpatient Prescription
Drug Rider.
The Network Out-of-Pocket Maximum includes all Network
cost sharing, except for Copayments or Coinsurance for
Covered Health Services provided under the Outpatient
Prescription Drug Rider.
Annual Maximum Benefit
The maximum amount we will pay for Non-Network Benefits
during the year. The Annual Maximum Benefit applies to
Covered Health Services under the Policy as indicated in this
Schedule of Benefits, including Covered Health Services
provided under the Outpatient Prescription Drug Rider.
Non-Network
No Annual Maximum Benefit.
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.

50% of the Eligible Expense.
Details about the way in which Eligible Expenses are determined appear at the end of the Schedule of
Benefits table.
Network services will not be subject to both a Copayment and a Coinsurance. If a Copayment applies,
there will not be any Coinsurance required of the Covered Person.
Coinsurance
Coinsurance is the amount you pay (calculated as a percentage of Eligible Expenses) each time you
receive certain Covered Health Services.
Benefits table.
SBN.CHP.I.11.NJ.R2
5
When Benefit limits apply, the limit refers to any combination of Network Benefits and NonNetwork Benefits unless otherwise specifically stated.
Covered Health Service
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
1. Ambulance Services
Prior Authorization Requirement
In most cases, we will initiate and direct non-Emergency ambulance transportation. If you are
requesting non-Emergency ambulance services, you must obtain authorization as soon as possible
prior to transport. If you fail to obtain prior authorization as required, Benefits will be reduced to 50% of
Eligible Expenses.
Emergency Ambulance
Network
Ground Ambulance:
100%
Yes
Yes
Yes
Yes
Same as Network
Same as Network
Yes
Yes
Yes
Yes
Same as Network
Same as Network
Air Ambulance:
100%
Non-Network
Same as Network
Non-Emergency Ambulance
Network
Ground or air ambulance, as we
determine appropriate.
Ground Ambulance:
100%
Air Ambulance:
100%
Non-Network
Same as Network
2. Autism Spectrum Disorder and
Other Developmental Disabilities Rehabilitative Services
For Non-Network Benefits you must obtain prior authorization five business days before receiving
physical therapy, occupational therapy and speech therapy or as soon as is reasonably possible. If you
fail to obtain prior authorization as required, Benefits will be reduced to 50% of Eligible Expenses.
For Non-Network Benefits for a scheduled admission, you must obtain prior authorization five business
days before admission, or as soon as is reasonably possible for non-scheduled admissions. If you fail
to obtain prior authorization as required, Benefits will be reduced to 50% of Eligible Expenses.
In addition, for Non-Network Benefits you must contact us 24 hours before admission for scheduled
admissions or as soon as is reasonably possible for non-scheduled admissions (including Emergency
SBN.CHP.I.11.NJ.R2
6
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
admissions).
Inpatient:
Network
Limited to 60 days per year.
Inpatient
100%
Outpatient
Outpatient
Limited per year as follows:
100% after you pay a
Copayment of $15
per visit

20 visits of physical therapy.

20 visits of occupational
therapy.

20 visits of speech therapy.
Non-Network
Inpatient
70%
Outpatient
70%
3. Clinical Trials
You must obtain prior authorization as soon as the possibility of participation in a clinical trial arises. If
you fail to obtain prior authorization as required, Benefits will be reduced to 50% of Eligible Expenses.
Depending upon the Covered Health
Service, Benefit limits are the same
as those stated under the specific
Benefit category in this Schedule of
Benefits.
Network
Depending upon where the Covered Health Service is
provided, Benefits will be the same as those stated under
each Covered Health Service category in this Schedule of
Benefits.
Non-Network
SBN.CHP.I.11.NJ.R2
7
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Benefits.
4. Congenital Heart Disease
Surgeries
For Non-Network Benefits you must obtain prior authorization as soon as the possibility of a congenital
heart disease (CHD) surgery arises. If you fail to obtain prior authorization as required, Benefits will be
reduced to 50% of Eligible Expenses.
Network and Non-Network Benefits
under this section include only the
inpatient facility charges for the
congenital heart disease (CHD)
surgery. Depending upon where the
Covered Health Service is provided,
Benefits for diagnostic services,
cardiac catheterization and nonsurgical management of CHD will be
the same as those stated under each
Covered Health Service category in
this Schedule of Benefits.
Network
100%
Yes
Yes
Yes
Yes
Non-Network
70%
5. Dental Services - Accident Only
For Network and Non-Network Benefits you must obtain prior authorization five business days before
follow-up (post-Emergency) treatment begins or as soon as is reasonably possible. (You do not have to
obtain prior authorization before the initial Emergency treatment.) If you fail to obtain prior authorization
as required, Benefits will be reduced to 50% of Eligible Expenses.
Network
100%
Yes
Yes
Same as Network
Same as Network
Non-Network
Same as Network
6. Dental Services - Other
SBN.CHP.I.11.NJ.R2
8
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Network
provided (Physician's Office Services, Outpatient Facility,
Physician's Fees for Surgical and Medical Services, Hospital Inpatient), Benefits will be the same as those stated under
Benefits.
Non-Network
Benefits.
7. Diabetes Services
For Non-Network Benefits you must obtain prior authorization before obtaining any Durable Medical
Equipment for the management and treatment of diabetes that exceeds $1,000 in cost (either retail
purchase cost or cumulative retail rental cost of a single item). If you fail to obtain prior authorization as
required, Benefits will be reduced to 50% of Eligible Expenses.
Diabetes Self-Management and
Training/Diabetic Eye
Examinations/Foot Care
Network
provided, Benefits for diabetes self-management and
training/diabetic eye examinations/foot care will be the same
as those stated under each Covered Health Service category
in this Schedule of Benefits.
Non-Network
Diabetes Self-Management Items
Network
Benefits for diabetes equipment that
meets the definition of Durable
Medical Equipment are not subject to
the limit stated under Durable Medical
provided, Benefits for diabetes self-management items will be
the same as those stated under Durable Medical Equipment
SBN.CHP.I.11.NJ.R2
9
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Equipment.
and in the Outpatient Prescription Drug Rider.
Non-Network
8. Durable Medical Equipment
Equipment that exceeds $1,000 in cost (either retail purchase cost or cumulative retail rental cost of a
single item). If you fail to obtain prior authorization as required, Benefits will be reduced to 50% of
Eligible Expenses.
Limited to $25,000 in Eligible
Expenses per year. Benefits are
limited to a single purchase of a type
of DME (including repair/replacement)
every three years. This limit does not
apply to wound vacuums.
Network
100%
Yes
Yes
Yes
Yes
Benefits for speech aid devices and
tracheo-esophageal voice devices are
limited to the purchase of one device
during the entire period of time a
Covered Person is enrolled under the
Policy. Benefits for repair/replacement
are limited to once every three years.
Speech aid and tracheo-esophageal
voice devices are included in the
annual limits stated above.
To receive Network Benefits, you
must purchase or rent the Durable
Medical Equipment from the vendor
we identify or purchase it directly from
the prescribing Network Physician.
Non-Network
70%
9. Emergency Health Services Outpatient
Note: If you are confined in a nonNetwork Hospital after you receive
SBN.CHP.I.11.NJ.R2
Network
10
Yes
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
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.
Copayment of $50
per visit. If you are
admitted as an
inpatient to a Network
Hospital directly from
the Emergency room,
you will not have to
pay this Copayment.
The Benefits for an
Inpatient Stay in a
Network Hospital will
apply instead.
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Yes
Non-Network
Same as Network
Same as Network
Same as Network
Yes
Yes
Yes
Yes
No
No
No
No
10. Hearing Aids
Limited to $2,500 per hearing aid for
each hearing impaired ear every 24
months. Accessories, fittings and
repairs are not subject to the $2,500
limit.
Network
Copayment of $15
per hearing aid
Non-Network
70%
11. Hearing Loss Screening
Network
No Copayment
Non-Network
No Copayment
12. Hemophilia Services
For Non-Network Benefits you must obtain prior authorization five business days prior to receiving
services or as soon as reasonably possible. If you fail to obtain prior authorization as required, Benefits
will be reduced to 50% of Eligible Expenses.
SBN.CHP.I.11.NJ.R2
11
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Yes
Yes
Yes
Yes
Network
100%
Non-Network
70%
13. Home Health Care
services or as soon as is reasonably possible. If you fail to obtain prior authorization as required,
Benefits will be reduced to 50% of Eligible Expenses.
Limited to 60 visits per year. One visit
equals up to four hours of skilled care
services.
Network
100%
Yes
Yes
Yes
Yes
This visit limit does not include any
service which is billed only for the
administration of intravenous infusion.
Non-Network
70%
14. Hospice Care
For Non-Network Benefits you must obtain prior authorization five business days before admission for
an Inpatient Stay in a hospice facility or as soon as is reasonably possible. If you fail to obtain prior
authorization as required, Benefits will be reduced to 50% of Eligible Expenses.
In addition, for Non-Network Benefits, you must contact us within 24 hours of admission for an Inpatient
Stay in a hospice facility.
Network
100%
Yes
Yes
Yes
Yes
Non-Network
70%
15. Hospital - Inpatient Stay
days before admission, or as soon as is reasonably possible for non-scheduled admissions (including
Emergency admissions). If you fail to obtain prior authorization as required, Benefits will be reduced to
SBN.CHP.I.11.NJ.R2
12
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
50% of Eligible Expenses.
admissions).
Your cost share for Covered Health Services rendered during a hospitalization in a Network Hospital
will be limited to the Copayment, deductible and/or Coinsurance applicable to Network Services as long
as all notification requirements have been met. This applies to Covered Health Services received at a
Network Hospital regardless of whether the admitting Physician is a Network or non-Network provider.
However, although the inpatient services will be treated as Network services, the services of the nonNetwork admitting physician will be treated as non-Network services.
Network
100%
Yes
Yes
Yes
Yes
Non-Network
70%
16. Infertility Services
You must obtain prior authorization as soon as possible. If you fail to obtain prior authorization as
Limited to four completed egg
retrievals per lifetime of the Covered
Person.
Network
Benefits.
Non-Network
Benefits.
17. Lab, X-Ray and Diagnostics Outpatient
Lab Testing - Outpatient:
Network
100%
Yes
Yes
Yes
Yes
Non-Network
70%
SBN.CHP.I.11.NJ.R2
13
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
X-Ray and Other Diagnostic
Testing - Outpatient:
Network
100%
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Non-Network
70%
18. Lab, X-Ray and Major
Diagnostics - CT, PET, MRI, MRA
and Nuclear Medicine - Outpatient
Network
100%
Non-Network
70%
19. Medical Foods
For Non-Network Benefits, you must obtain prior authorization as soon as possible. If you fail to obtain
prior authorization as required, Benefits will be reduced to 50% of Eligible Expenses.
Network
100%
Yes
Yes
Yes
Yes
Non-Network
70%
20. Mental Health Services
For Non-Network Benefits for a scheduled admission for Mental Health Services (including an
admission for Partial Hospitalization/Day Treatment and services at a Residential Treatment Facility)
you must obtain authorization prior to the admission or as soon as is reasonably possible for nonscheduled admissions (including Emergency admissions).
In addition, for Non-Network Benefits you must obtain prior authorization before the following services
are received. Services requiring prior authorization: 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.
If you fail to obtain prior authorization as required, Benefits will be reduced to 50% of Eligible
Expenses.
Network
SBN.CHP.I.11.NJ.R2
14
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Inpatient
100%
Outpatient
Copayment of $15
per visit
Non-Network
Inpatient
70%
Outpatient
70%
21. Neurobiological Disorders Autism Spectrum Disorder
Services
For Non-Network Benefits for a scheduled admission for Neurobiological Disorders - Autism Spectrum
Disorder Services (including an admission for Partial Hospitalization/Day Treatment and services at a
Residential Treatment Facility) you must obtain authorization prior to the admission or as soon as is
reasonably possible for non-scheduled admissions (including Emergency admissions).
psychological testing; extended outpatient treatment visits beyond 45-50 minutes in duration, with or
without medication management; Applied Behavioral Analysis.
Expenses.
Network
Inpatient
100%
Yes
Yes
Yes
Yes
Outpatient
Copayment of $15
per visit
Non-Network
SBN.CHP.I.11.NJ.R2
15
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Yes
Yes
70%
Yes
Yes
Copayment of $15
per visit
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Inpatient
70%
Outpatient
22. New Jersey Early Intervention
Family Cost Share Expense
The Annual Deductible, Coinsurance
or Copayment as applicable to a nonSpecialist Physician visit for treatment
of a Sickness or Injury will apply to
the monthly Family Cost Share
expense.
23. Ostomy Supplies
Limited to $2,500 per year.
Network
100%
Non-Network
70%
24. Pharmaceutical Products Outpatient
Network
100%
Non-Network
70%
25. Physician Fees for Surgical and
Medical Services
Network
100%
Covered Health Services provided by
a non-Network consulting Physician,
assistant surgeon or a surgical
assistant in a Network facility will be
SBN.CHP.I.11.NJ.R2
Non-Network
70%
16
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
paid as Network Benefits. In order to
obtain the highest level of Benefits,
you should confirm the Network
status of these providers prior to
obtaining Covered Health Services.
26. Physician's Office Services Sickness and Injury
For Non-Network Benefits you must obtain prior authorization as soon as reasonably possible before
Genetic Testing, including BRCA Genetic Testing is performed. If you fail to obtain prior authorization
In addition to the office visit
Copayment stated in this section, the
Copayments/Coinsurance and any
deductible for the following services
apply when the Covered Health
Service is performed in a Physician's
office:

Major diagnostic and nuclear
medicine described under Lab,
X-Ray and Major Diagnostics CT, PET, MRI, MRA and
Nuclear Medicine - Outpatient.

Outpatient Pharmaceutical
Products described under
Pharmaceutical Products Outpatient.

Diagnostic and therapeutic
scopic procedures described
under Scopic Procedures Outpatient Diagnostic and
Therapeutic.

Outpatient surgery procedures
described under Surgery Outpatient.

Outpatient therapeutic
procedures described under
Therapeutic Treatments Outpatient.
SBN.CHP.I.11.NJ.R2
Network
Copayment of $15
per visit for a Primary
Physician office visit
or $30 per visit for a
Specialist Physician
office visit
17
Yes
Yes
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Yes
Yes
Non-Network
70%
27. Pregnancy - Maternity Services
For Non-Network Benefits you must obtain prior authorization as soon as reasonably possible if the
Inpatient Stay for the mother and/or the newborn will be more than 48 hours for the mother and
newborn child following a normal vaginal delivery, or more than 96 hours for the mother and newborn
child following a cesarean section delivery. If you fail to obtain prior authorization as required, Benefits
It is important that you notify us regarding your Pregnancy. Your notification will open the
opportunity to become enrolled in prenatal programs that are designed to achieve the best
outcomes for you and your baby.
Network
Benefits will be the same as those stated under each Covered
Health Service category in this Schedule of Benefits except
that an Annual Deductible will not apply for a newborn child
whose length of stay in the Hospital is the same as the
mother's length of stay. For Covered Health Services provided
in the Physician's Office, a Copayment will apply only to the
initial office visit.
Non-Network
mother's length of stay.
28. Preventive Care Services
Physician office services
Network
100%
No
No
Yes
Yes
No
No
Non-Network
70%
Lab, X-ray or other preventive tests
Network
Please note the Annual Deductible
does not apply to Non-Network lead
poisoning screenings for children.
100%
SBN.CHP.I.11.NJ.R2
18
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Yes
Yes
Yes
Yes
Yes
Yes
Non-Network
70%
29. Prosthetic and Orthotic Devices
Please note: Reimbursement for
these items will be at the same rate
as under the federal Medicare
reimbursement schedule.
Network
Copayment of $15
per item
Non-Network
70%
30. Reconstructive Procedures
For Non-Network Benefits you must obtain prior authorization five business days before a scheduled
reconstructive procedure is performed or, for non-scheduled procedures, within one business day or as
soon as is reasonably possible. If you fail to obtain prior authorization as required, Benefits will be
inpatient admissions or as soon as is reasonably possible for non-scheduled inpatient admissions
(including Emergency admissions).
Network
Benefits.
Non-Network
Benefits.
31. Rehabilitation Services Outpatient Therapy and
Manipulative Treatment
Manipulative Treatment or as soon as is reasonably possible. If you fail to obtain prior authorization as
SBN.CHP.I.11.NJ.R2
19
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Network


therapy.
Copayment of $15
per visit

20 Manipulative Treatments.


20 visits of pulmonary
rehabilitation therapy.

36 visits of cardiac

30 visits of post-cochlear
implant aural therapy.

20 visits of cognitive
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Non-Network
70%
32. Scopic Procedures - Outpatient
Diagnostic and Therapeutic
Network
100%
Non-Network
70%
33. Skilled Nursing
Facility/Inpatient Rehabilitation
Facility Services
admissions).
SBN.CHP.I.11.NJ.R2
20
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Network
100%
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Yes
Yes
Yes
Yes
Non-Network
70%
34. Specialized Non-Standard
Infant Formulas
For Non-Network Benefits, you must obtain prior authorization at least 5 business days before
purchasing the formula, or as soon as is reasonably possible.
Network
100%
Yes
Yes
Yes
Yes
Non-Network
70%
35. Substance Use Disorder
Services
For Non-Network Benefits for a scheduled admission for Substance Use Disorder Services (including
an admission for Partial Hospitalization/Day Treatment and services at a Residential Treatment
Facility) you must obtain authorization prior to the admission or as soon as is reasonably possible for
non-scheduled admissions (including Emergency admissions).
psychological testing; extended outpatient treatment visits beyond 45 - 50 minutes in duration, with or
without medication management.
Expenses.
Network
Inpatient
100%
Yes
Yes
Yes
Yes
Outpatient
Copayment of $15
per visit
SBN.CHP.I.11.NJ.R2
21
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Yes
Yes
Yes
Yes
Non-Network
Inpatient
70%
Outpatient
70%
36. Surgery - Outpatient
For Non-Network Benefits for pain management procedures, diagnostic catheterization and
electrophysiology implant and sleep apnea surgery you must obtain prior authorization five business
days before scheduled services are received or, for non-scheduled services, within one business day
or as soon as is reasonably possible. If you fail to obtain prior authorization as required, Benefits will be
Network
100%
Yes
Yes
Yes
Yes
Non-Network
70%
37. Therapeutic Treatments Outpatient
For Non-Network Benefits you must obtain prior authorization for the following outpatient therapeutic
services five business days before scheduled services are received or, for non-scheduled services,
within one business day or as soon as is reasonably possible. Services that require prior authorization:
dialysis, intensity modulated radiation therapy and MR-guided focused ultrasound. If you fail to obtain
Network
100%
Yes
Yes
Yes
Yes
Non-Network
70%
38. Transplantation Services
For Network Benefits you must obtain prior authorization as soon as the possibility of a transplant
arises (and before the time a pre-transplantation evaluation is performed at a transplant center). If you
don't obtain prior authorization and if, as a result, the services are not performed at a Designated
SBN.CHP.I.11.NJ.R2
22
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Facility, Network Benefits will not be paid. Non-Network Benefits will apply.
For Non-Network Benefits you must obtain prior authorization as soon as the possibility of a transplant
admissions).
Network
For Network Benefits, transplantation
services must be received at a
Designated Facility. We do not
provided,
Benefits will be the same as those stated under
require that cornea transplants be
each
Covered
Health Service category in this Schedule of
performed at a Designated Facility in
Benefits.
order for you to receive Network
Benefits.
Non-Network Benefits are limited to
$200,000 per transplant. This limit
does not apply to autologous bone
marrow transplants or peripheral
blood stem cell transplants.
Non-Network
Benefits.
39. Urgent Care Center Services
In addition to the Copayment stated in
this section, the
Copayments/Coinsurance and any
deductible for the following services
apply when the Covered Health
Service is performed at an Urgent
Care Center:

Major diagnostic and nuclear
medicine described under Lab,
X-Ray and Major Diagnostics CT, PET, MRI, MRA and
Nuclear Medicine - Outpatient.

Outpatient Pharmaceutical
Products described under
Pharmaceutical Products Outpatient.

Diagnostic and therapeutic
scopic procedures described
under Scopic Procedures Outpatient Diagnostic and
Therapeutic.
SBN.CHP.I.11.NJ.R2
Network
Copayment of $25
per visit
23
Yes
Yes

Outpatient surgery procedures
described under Surgery Outpatient.

Outpatient therapeutic
procedures described under
Therapeutic Treatments Outpatient.
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Yes
Yes
Yes
Yes
Yes
Yes
Non-Network
70%
40. Vision Examinations
Limited to 1 exam every 2 years.
Network
Copayment of $15
per visit
Non-Network
70%
Eligible Expenses
Eligible Expenses are the amount we determine that we will pay for Benefits. For Network Benefits, 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 non-Network providers as arranged by us,
Eligible Expenses are the fee(s) that we negotiate with the non-Network provider.

When Covered Health Services are received from a non-Network provider as a result of an
Emergency, Eligible Expenses are the provider's usual, customary and reasonable charges which
are, in our judgment, representative of the average and prevailing charge for the same health
service in the same or similar geographic communities where the health service is rendered.
For Non-Network Benefits, Eligible Expenses are based on either of the following:
SBN.CHP.I.11.NJ.R2
24

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 150% 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.
♦
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
that uses a relative value scale, which is usually based on the difficulty, time,
work, risk and resources of the service. The relative value scale currently used
is created by Ingenix, Inc. If the Ingenix, Inc. relative value scale becomes no
longer available, a comparable scale will be used. We and Ingenix, Inc. are
related companies through common ownership by UnitedHealth Group.

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, or the provider does not submit sufficient information on the claim
to pay it under CMS published rates or a gap methodology, the Eligible Expense is
based on 50% of the provider's billed charge, except that certain Eligible Expenses for
Mental Health Services and Substance Use Disorder Services are based on 80% of
the billed charge.
♦
For Mental Health Services and Substance Use Disorder Services the Eligible
Expense will be reduced by 25% for Covered Health Services provided by a
psychologist and by 35% for Covered Health Services provided by a masters level
counselor.
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.

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
SBN.CHP.I.11.NJ.R2
25
available online at www.myuhc.com or by calling Customer Care at the telephone number on your ID card
to request a copy.
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.
Not all Network Hospitals are contracted to perform transplants. Please refer to your provider directory or
contact us to find out which hospitals are contracted for this service.
Continuation of Treatment when a Physician Leaves the Network
If a Covered Person is receiving post-operative follow-up care, oncological treatment, psychiatric
treatment or obstetrical care by a Physician who was a Network Physician at the time the treatment was
initiated, the Covered Person may continue to be treated by that Physician for the duration of the
treatment even if the Physician leaves the Network. The continued treatment is subject to the following
time periods:

Up to six months for post-operative follow-up care.

Up to one year for oncological treatment and psychiatric treatment.

Through the duration of a pregnancy and up to six weeks after delivery for obstetrical care.

Up to four months for other Health Services where it is medically necessary for the Covered Person
to continue treatment with that Physician.

Health Services for the continued treatment are covered as Network Benefits. Reimbursement for
Health Services will be made according to the same fee schedule used for Network Services.

During the time a Covered Person receives continued treatment by a Physician who has left the
Network, we will provide Network Benefits for any treatment or services provided to the Covered
Person in a Hospital, regardless of whether the Hospital is a Network Hospital.
Designated Facilities and Other Providers
For Transplants, we may direct you to a Designated Facility chosen by us. If you require certain complex
Covered Health Services for which expertise is limited, we may direct you to a Network facility or provider
that is outside your local geographic area. If you reside more than 50 miles from the Designated Facility
and are required to travel to obtain such Covered Health Services from the Designated Facility, we will
provide for reimbursement of travel and lodging expenses for the Covered Person and one companion.
Coverage is limited to $50/$100 lodging per day, up to a maximum Benefit of $10,000 per lifetime.
In both cases, Network Benefits will only be paid if your Covered Health Services for that condition are
provided by or arranged by the Designated Facility or other provider chosen by us.
You or your Network Physician must notify us of special service needs that might warrant referral to a
Designated Facility. If you do not notify us in advance, and if you receive services from a non-Network
facility (regardless of whether it is a Designated Facility) or other non-Network provider, Network Benefits
will not be paid. Non-Network Benefits may be available if the special needs services you receive are
Covered Health Services for which Benefits are provided under the Policy.
SBN.CHP.I.11.NJ.R2
26
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.
SBN.CHP.I.11.NJ.R2
27
Certificate of Coverage is Part of Policy
This Certificate of Coverage (Certificate) is part of the Policy that is a legal document between
UnitedHealthcare Insurance Company and the Enrolling Group to provide Benefits to Covered Persons,
subject to the terms, conditions, exclusions and limitations of the Policy. We issue the Policy based on the
Enrolling Group's application and payment of the required Policy Charges.
In addition to this Certificate the Policy includes:

The Group Policy.

The Schedule of Benefits.

The Enrolling Group's application.

Riders.

Amendments.
You can review the Policy at the office of the Enrolling Group during regular business hours.
Changes to the Document
We may from time to time modify this Certificate by attaching legal documents called Riders and/or
Amendments that may change certain provisions of this Certificate. When that happens we will send you
a new Certificate, Rider or Amendment pages.
No one can make any changes to the 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 the Policy, as
permitted by law, without your approval.
On its effective date, this Certificate replaces and overrules any Certificate that we may have previously
issued to you. This Certificate will in turn be overruled by any Certificate we issue to you in the future.
The Policy will take effect on the date specified in the Policy. Coverage under the Policy will begin at
12:01 a.m. and end at 12:00 midnight in the time zone of the Enrolling Group's location. The Policy will
remain in effect as long as the Policy Charges are paid when they are due, subject to termination of the
Policy.
We are delivering the Policy in the State of New Jersey and the Policy is subject to the laws of New
Jersey. The Policy is then governed by ERISA unless the Enrolling Group is not an employee welfare
benefit plan as defined by ERISA.
COC.CER.I.11.NJ
1
Introduction to Your Certificate
We are pleased to provide you with this Certificate. This Certificate and the other Policy documents
describe your Benefits, as well as your rights and responsibilities, under the Policy.
How to Use this Document
We encourage you to read your Certificate and any attached Riders and/or Amendments carefully.
We especially encourage you to review the Benefit limitations of this Certificate 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 8: General Legal Provisions to better understand how
this Certificate 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 Certificate 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
Certificate and Schedule of Benefits and any attachments in a safe place for your future reference.
If there is a conflict between this Certificate and any summaries provided to you by the Enrolling Group,
this Certificate will control.
Please be aware that your Physician is not responsible for knowing or communicating your Benefits.
Information about Defined Terms
Because this Certificate is part of 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 9: Defined Terms. You can refer to Section 9: Defined Terms as you read this document
to have a clearer understanding of your Certificate.
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 9: 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 ID card. It will be our pleasure to assist you.
COC.INT.I.11.NJ
2
Your Responsibilities
Be Enrolled and Pay Required Contributions
Benefits are available to you only if you are enrolled for coverage under the Policy. Your enrollment
options, and the corresponding dates that coverage begins, are listed in Section 3: When Coverage
Begins. To be enrolled with us and receive Benefits, both of the following apply:

Your enrollment must be in accordance with the Policy issued to your Enrolling Group, including
the eligibility requirements.

You must qualify as a Subscriber or his or her Dependent as those terms are defined in Section 9:
Defined Terms.
Your Enrolling Group may require you to make certain payments to them, in order for you to remain
enrolled under the Policy and receive Benefits. If you have questions about this, contact your Enrolling
Group.
Be Aware this Benefit Plan Does Not Pay for All Health Services
Your right to Benefits is limited to Covered Health Services. The extent of this Benefit plan'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
We understand that there are many variables that influence the decisions you make regarding your care,
including the coverage available under this plan. However, final care decisions are between you and your
Physicians. Your Physicians are solely responsible for all health services that you 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 pay a Copayment 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.
COC.YRP.I.11.NJ
3
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 Benefit plan's exclusions.
Show Your ID Card
You should show your identification (ID) card or have your provider verify your eligibility by calling us
every time you request health services. If you do not show your ID card or have your provider verify your
eligibility, 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. If you have not received
your ID card from us, or if you have lost your ID card, please contact us as soon as possible. If you need
to seek services and do not have your ID card, please direct your provider to verify your eligibility by
calling us to ensure proper payment of claims.
File Claims with Complete and Accurate Information
When you receive Covered Health Services from a non-Network provider, you have the right to make an
assignment of benefits, whereby your provider may request payment from us. You may also request
payment on your own behalf at your option. Claims must be filed 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 Benefit plan for all other
Covered Health Services that are not related to the condition or disability for which you have other
coverage.
COC.YRP.I.11.NJ
4
Our Responsibilities
Determine Benefits
We make administrative decisions regarding whether this Benefit plan will pay for any portion of the cost
of a health care service you intend to receive or have received. Our decisions are for payment purposes
only. 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.
Subject to your appeal rights set forth in the Questions, Complaints and Appeals procedures section, we
will do the following:

Make an initial interpretation of Benefits and the other terms, limitations and exclusions set out in
this Certificate, 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 Benefit plan, such as claims processing. The identity of the service providers and the nature of their
services may be changed from time to time in our discretion. 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 Benefit plan.
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 or your
non-Network provider's 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.
COC.ORP.I.11.NJ
5

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
obtain copies of our reimbursement policies for yourself or to share with your non-Network Physician or
provider by going to www.myuhc.com or 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.
COC.ORP.I.11.NJ
6
Certificate of Coverage Table of Contents
COC.TOC.I.11.NJ
7
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 or medically appropriate. (See definitions of Medically Necessary and
Covered Health Service in Section 9: 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 use disorder, disease or its symptoms
does not mean that the procedure or treatment is a Covered Health Service under the Policy.

Covered Health Services are received while the Policy is in effect or during any extension of
benefits period.

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 specified in the Policy.
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 you are required to pay in a year (Out-of-Pocket 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."
Emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance)
to the nearest Hospital where Emergency Health Services can be performed.
Non-Emergency ambulance transportation by a licensed ambulance service (either ground or air
ambulance, as we determine appropriate) between facilities when the transport is any of the following:

From a non-Network Hospital to a Network Hospital.

To a Hospital that provides a higher level of care that was not available at the original Hospital.

To a more cost-effective acute care facility.

From an acute facility to a sub-acute setting.
COC.CHS.I.11.NJ
8
2. Autism Spectrum Disorder and Other Developmental Disabilities –
Rehabilitative Services
For Covered Persons with a primary diagnosis of Autism Spectrum Disorder or another Developmental
Disability, Benefits under this section include:

Physical therapy provided by a licensed physical therapist.

Speech and language pathology services provided by a licensed speech and language pathologist.

Occupational therapy provided by a licensed occupational therapist.
Benefits for these therapies will be provided as prescribed through a treatment plan and will not be denied
on the basis that the treatment is not restorative.
The treatment plan must include all elements necessary to appropriately provide Benefits, including, but
not limited to:

a diagnosis;

proposed treatment by type, frequency, and duration;

the anticipated outcomes stated as goals; the frequency by which the treatment plan will be
updated;

and the treating Physician’s signature.
We may request an updated treatment plan once every six months from your Physician to review medical
necessity, unless a more frequent review is agreed upon due to emerging clinical circumstances.
Please note, Benefits for psychiatric treatment for Autism Spectrum Disorder (including evaluation and
assessment services, applied behavior analysis and behavior training and behavior management) are
described above under Neurobiological Disorders - Autism Spectrum Disorder Services.
3. Clinical Trials
Routine patient care costs incurred during participation in a qualifying clinical trial for the treatment of:

Cancer.

Cardiovascular disease (cardiac/stroke).

Surgical musculoskeletal disorders of the spine, hip and knees.

Other diseases or disorders 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 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 clinical
trial as defined by the researcher. Benefits are not available for preventive clinical trials.
Routine patient care costs for 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 Investigational item or service, the
clinically appropriate monitoring of the effects of the item or service, or the prevention of
complications.
COC.CHS.I.11.NJ
9

Covered Health Services needed for reasonable and necessary care arising from the provision of
an Investigational item or service.
Routine costs for clinical trials do not include:

The Experimental or Investigational Service 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.

Items and services provided by the research sponsors free of charge for any person enrolled in the
trial.
To be a qualifying clinical trial, a clinical trial must meet all of the following criteria:

Be sponsored and provided by a cancer center that has been designated by the National Cancer
Institute (NCI) as a Clinical Cancer Center or Comprehensive Cancer Center or be sponsored by
any of the following:

National Institutes of Health (NIH). (Includes National Cancer Institute (NCI).)

Centers for Disease Control and Prevention (CDC).

Agency for Healthcare Research and Quality (AHRQ).

Centers for Medicare and Medicaid Services (CMS).

Department of Defense (DOD).

Veterans Administration (VA).

The clinical trial must have a written protocol that describes a scientifically sound study and have
been approved by all relevant institutional review boards (IRBs) before participants are enrolled in
the trial. We may, at any time, request documentation about the trial.

The subject or purpose of the trial must be the evaluation of an item or service that meets the
definition of a Covered Health Service and is not otherwise excluded under the Policy.
4. Congenital Heart Disease Surgeries
Congenital heart disease (CHD) surgeries which are ordered by a Physician. CHD surgical procedures
include surgeries to treat conditions such as coarctation of the aorta, aortic stenosis, tetralogy of fallot,
transposition of the great vessels and hypoplastic left or right heart syndrome.
Benefits under this section include the facility charge and the charge for supplies and equipment. Benefits
for Physician services are described under Physician Fees for Surgical and Medical Services.
Surgery may be performed as open or closed surgical procedures or may be performed through
interventional cardiac catheterization.
We have specific guidelines regarding Benefits for CHD services. Contact us at the telephone number on
your ID card for information about these guidelines.
COC.CHS.I.11.NJ
10
Dental services when all of the following are true:

Treatment is necessary because of accidental damage.

Dental services are received from a Doctor of Medicine, "M.D.", Doctor of Dental Surgery, "D.D.S."
or Doctor of Medical Dentistry, "D.M.D.".

The dental damage is severe enough that initial contact with a Physician or dentist occurred within
72 hours of the accident. (You may request an extension of this time period provided that you do so
within 60 days of the Injury and if extenuating circumstances exist due to the severity of the Injury.)
Please note that dental damage that occurs as a result of normal activities of daily living or extraordinary
use of the teeth is not considered having occurred as an accident. Benefits are not available for repairs to
teeth that are damaged as a result of such activities.
Dental services to repair damage caused by accidental Injury must conform to the following time-frames:

Treatment is started within three months of the accident, unless extenuating circumstances exist
(such as prolonged hospitalization or the presence of fixation wires from fracture care).

Treatment must be completed within 12 months of the accident.
Benefits for treatment of accidental Injury are limited to the following:

Emergency examination.

Necessary diagnostic X-rays.

Endodontic (root canal) treatment.

Temporary splinting of teeth.

Prefabricated post and core.

Simple minimal restorative procedures (fillings).

Extractions.

Post-traumatic crowns if such are the only clinically acceptable treatment.

Replacement of lost teeth due to the Injury by implant, dentures or bridges.
Services including surgery, general anesthesia and associated Hospital or Alternate Facility charges
when the dentist and Physician determine that the services are necessary for the safe and effective
treatment of one of the following:

A dental condition.

A medical condition covered under the Policy which requires hospitalization or general anesthesia
for dental services rendered by a Doctor of Medicine, "M.D.", Doctor of Dental Surgery, "D.D.S.", or
Doctor of Medical Dentistry "D.M.D." regardless of where the dental services are provided.
Services are limited to Covered Persons who are one of the following:

A child under 5 years of age.

A person who is severely disabled.
COC.CHS.I.11.NJ
11
Services for the diagnosis or treatment of a dental disease are not Covered Health Services.
Diabetes Self-Management and Training/Diabetic Eye Examinations/Foot Care
Outpatient self-management training for the treatment of diabetes, education and medical nutrition
therapy services to ensure that a person with diabetes is educated regarding the proper self-management
and treatment of their diabetic condition, including information on proper diet. Diabetes outpatient selfmanagement training, education and medical nutrition therapy services must be ordered by a Physician
and provided by appropriately licensed or registered healthcare professionals.
Covered services for self-management and diet education are limited to the following:

Visits as Medically Necessary upon the diagnosis of diabetes.

Visits as Medically Necessary upon diagnosis by a Physician or nurse practitioner/clinical nurse
specialist of a significant change in the person's symptoms or conditions which necessitate
changes in that person's self-management.

Visits as Medically Necessary upon the determination of a Physician or nurse practitioner/clinical
nurse specialist that reeducation or refresher education is necessary.
Diabetes self-management education must be provided by one of the following:

A dietitian who is registered by a nationally-recognized professional association of dietitians.

A health care professional recognized as a certified diabetes educator by the American Association
of Diabetes Educators.

A registered pharmacist qualified regarding management education for diabetes by any institution
recognized by the Board of Pharmacy of the State of New Jersey.
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. Benefits for blood glucose monitors and blood glucose monitors for the
legally blind, insulin syringes with needles, test strips for glucose monitors and visual reading and urine
testing strips, ketone test strips and tablets, insulin, injection aids, oral agents for controlling blood sugar
and lancets and lancet devices are described under the Outpatient Prescription Drug Rider.

Blood glucose monitors and blood glucose monitors for the legally blind.

Insulin syringes with needles.

Test strips for glucose monitors and visual reading and urine testing strips.

Ketone test strips and tablets.

Insulin.

Injection aids.

Oral agents for controlling blood sugar.

Lancets and lancet devices.
COC.CHS.I.11.NJ
12
The equipment and supplies must be recommended or prescribed by a Physician or nurse
practitioner/clinical nurse specialist.
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:

Mobility Devices.

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 Certificate.
Benefits under this section also include speech aid devices and tracheo-esophageal voice devices
required for treatment of severe speech impediment or lack of speech directly attributed to Sickness or
Injury. Benefits for the purchase of speech aid devices and tracheo-esophageal voice devices are
available only after completing a required three-month rental period. Benefits are limited as stated in the
Schedule of Benefits.
Benefits under this section do not include any device, appliance, pump, machine, stimulator, or monitor
that is fully implanted into the body.
We will decide if the equipment should be purchased or rented.
COC.CHS.I.11.NJ
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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.
9. 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.
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).
10. Hearing Aids
Hearing aids required for the correction of a hearing impairment (a reduction in the ability to perceive
sound which may range from slight to complete deafness). Hearing aids are electronic amplifying devices
designed to bring sound more effectively into the ear.
Benefits are available for a hearing aid that is purchased as a result of a written recommendation by a
Physician. Benefits are provided for the hearing aid and associated accessories, as well as for charges
associated with the fitting, testing and repair of a hearing aid.
Benefits under this section do not include bone anchored hearing aids. Bone anchored hearing aids are a
Covered Health Service for which Benefits are available under the applicable medical/surgical Covered
Health Services categories in this Certificate, only for Covered Persons who have either of the following:

Craniofacial anomalies whose abnormal or absent ear canals preclude the use of a wearable
hearing aid.

Hearing loss of sufficient severity that it would not be adequately remedied by a wearable hearing
aid.
Coverage for screening for newborn hearing loss by appropriate electrophysiologic screening measures
and periodic monitoring of infants for delayed onset hearing loss. No Copayment amount or Annual
Deductible applies to these Benefits.
Coverage is provided for home treatment of routine bleeding episodes due to hemophilia. The treatment
must be supervised by a state-approved hemophilia treatment center. Coverage is provided for blood
products including, but not limited to Factor VIII, Factor IX and Cryoprecipitate. Coverage is also provided
for blood infusion equipment including, but not limited to, syringes and needles.
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.
COC.CHS.I.11.NJ
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Benefits are available when the Home Health Agency services are provided on a part-time, Intermittent
Care schedule and when skilled care is required or when continued hospitalization would otherwise be
required.
Benefits are available for full-time nursing care and full-time care by an aide on a short-term basis if
needed. Home Health Agency services include physical, occupational, or speech therapy, medical social
work and nutritional services.
Benefits are available for the following items to the extent that they would have been available if the
Covered Person were confined in a Hospital:

Medical supplies.

Drugs and medications ordered by a Physician.

Laboratory services given or ordered in a Hospital.

Special meals.

Diagnostic, therapeutic or surgical services provided on an outpatient basis at a Hospital or
Alternate Facility or in a Physician's office.
Skilled care is skilled nursing, skilled teaching, skilled rehabilitation services, and home health aide
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.
14. 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.
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).
COC.CHS.I.11.NJ
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
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 simple mastectomy.

72 hours following a modified radical mastectomy.
If you agree, the attending provider may discharge you earlier than these minimum time frames.
Your cost share for Covered Health Services rendered during a hospitalization in a Network Hospital will
be limited to the Copayment, deductible or Coinsurance applicable to Network Services as long as all
request for pre-authorization requirements have been met. Please refer to your Schedule of Benefits for
the Copayment, deductible, Coinsurance and pre-authorization requirements that apply to your plan. This
applies to Covered Health Services received at a Network Hospital regardless of whether the admitting
Physician is a Network or non-Network provider. However, although the inpatient services will be treated
as Network services, the services of the non-Network admitting Physician will be treated as non-Network
services.
Benefits for Infertility will be paid at the same level as Benefits for any other maternity-related procedure.
Diagnosis and treatment of Infertility including but not limited to:

Diagnosis and diagnostic tests.

Medications.

Surgery.

In vitro fertilization.

Embryo transfer.

Zygote intra fallopian transfer.

Intracytoplasmic sperm injection.

Gamete intra fallopian transfer.

Four completed egg retrievals per lifetime of the Covered Person.

Medical costs of egg and sperm donors.
Benefits for gamete intra fallopian transfer, in vitro fertilization and zygote intra fallopian transfer are
limited to a Covered Person who meets all of the following conditions:

The Covered Person has used all reasonable, less expensive and medically appropriate treatments
and is still unable to become pregnant or carry a pregnancy.

The Covered Person has not reached the limit of four completed egg retrievals.

The Covered Person is 45 years of age or younger.
Services must be performed at facilities that conform to standards established by the American Society
for Reproductive Medicine or the American College of Obstetrics and Gynecologists.
COC.CHS.I.11.NJ
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17. 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 include:

Lab and radiology/X-ray.
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.)
When these services are performed in a Physician's office, Benefits are described under Physician's
Office Services - Sickness and Injury.
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.
18. Lab, X-Ray & 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.


19. Medical Foods
Benefits for Medical Foods and Low Protein Modified Food Products when prescribed for the therapeutic
treatment of Inherited Metabolic Diseases and administered under the direction of a Physician.
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.
This section does not include services related to Autism Spectrum Disorders. Treatment for Autism
Spectrum Disorder is a Covered Health Service for which Benefits are payable as described under
Neurobiological Disorders - Autism Spectrum Disorder Services.
Benefits include the following services provided on either an inpatient or outpatient basis:

Diagnostic evaluations and assessment.

Treatment planning.

Referral services.

Medication management.

Individual, family, therapeutic group and provider-based case management services.
COC.CHS.I.11.NJ
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
Crisis intervention.
Benefits include the following services provided on an inpatient basis:

Partial Hospitalization/Day Treatment.

Services at a Residential Treatment Facility.
Benefits include the following services provided on an outpatient basis:

Intensive Outpatient Treatment.
Benefits under this section include Biologically Based Mental Illness as required by New Jersey insurance
law.
The Mental Health/Substance Use Disorder 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 Use Disorder 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 Use Disorder
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 the Policy. You must be referred to such programs through the Mental
Health/Substance Use Disorder 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.
21. Neurobiological Disorders - Autism Spectrum Disorder Services
Psychiatric services 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 for Autism Spectrum
Disorders 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.
This section describes only the psychiatric component of treatment for Autism Spectrum Disorders.
Medical treatment of Autism Spectrum Disorders is a Covered Health Service for which Benefits are
available as described under Autism Spectrum Disorder and Other Developmental Disabilities –
Rehabilitative Services. Benefits include the following services provided on either an inpatient or
outpatient basis:


Treatment planning.

Referral services.

COC.CHS.I.11.NJ
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




For Covered Persons under 21 years of age, and when the primary diagnosis is autism, Benefits are
provided for Medically Necessary Behavioral Interventions Based on the Principles of Applied Behavioral
Analysis (“ABA”) and Related Structured Behavioral Programs as prescribed through a treatment plan
and provided by or under the direct supervision of an experienced individual who is credentialed by the
national Behavior Analyst Certification Board as either:

Board Certified Behavior Analyst – Doctoral (BCBA-D); or

Board Certified Behavior Analyst (BCBA).
22. New Jersey Early Intervention Family Cost Share Expense
Benefits under this section include the Family Cost Share expense incurred by Covered Persons for the
provision of certain health care services obtained in accordance with a treatment plan developed as a
result of, or in conjunction with, an Individualized Family Service Plan (IFSP) for a child determined
eligible for early intervention services through the New Jersey Early Intervention System (NJEIS).
In order to be eligible for reimbursement, the Covered Person must:
a)
be eligible for early intervention services through the New Jersey Early Intervention System;
b)
have been diagnosed with Autism Spectrum Disorder or another Developmental Disability; and
c)
received physical therapy, occupational therapy, speech therapy, applied behavior analysis or
related structured behavior services.
The portion of the Family Cost Share attributable to such services is a Covered Health Service under the
Policy. The deductible, Coinsurance or Copayment as applicable to a non-Specialist Physician visit for
treatment of a Sickness or Injury will apply to the monthly Family Cost Share expense.
The therapy services a Covered Person received through New Jersey Early Intervention do not reduce
the therapy services otherwise available under the Policy.
23. Ostomy Supplies
Benefits for ostomy supplies are limited to the following:

Pouches, face plates and belts.

Irrigation sleeves, bags and ostomy irrigation catheters.
COC.CHS.I.11.NJ
19

Skin barriers.
Benefits are not available for deodorants, filters, lubricants, tape, appliance cleaners, adhesive, adhesive
remover, or other items not listed above.
24. 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. Benefits under this section do not
include medications for the treatment of infertility.
Benefits for certain Pharmaceutical Products are subject to the supply limits that are stated in the
Schedule of Benefits. For a single Copayment and/or Coinsurance, you may receive Pharmaceutical
Products 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 order or
refill and/or the amount dispensed per month's supply.
You may determine whether a Pharmaceutical 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.
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.
25. 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.
Physician fees for a second opinion, including the review of the results of any laboratory and radiology
essential to the second opinion, where another licensed Physician proposes to perform an elective
inpatient surgical procedure on a Covered Person. For purposes of this benefit, an inpatient surgical
procedure is one which is scheduled at the convenience of the Covered Person or the covered Person's
Physician without jeopardizing the Covered Person's life or causing serious impairment to the Covered
Person's bodily functions. If the second surgical opinion does not confirm that the proposed elective
surgical procedure is medically advisable, then Physician Fees for a third surgical opinion shall be
covered in the same manner as those covered for a second surgical opinion. A Physician providing a
second or third surgical opinion shall be a physician who is licensed to practice medicine and surgery who
holds the rank of Diplomate of an American Board (M.D.) or Certified Specialist (O.D.) in the surgical or
medical specialty for which surgery is proposed. In the event that the Physician who provides a second or
third surgical opinion also performs the elective surgical procedure being proposed, then no benefits for
the second or third opinion will be paid to that Physician.
COC.CHS.I.11.NJ
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26. 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 injections.
Covered Health Services for preventive care provided in a Physician's office are described under
Preventive Care Services.
Benefits under this section include lab, radiology/X-ray or other diagnostic services performed in the
Physician's office. Benefits under this section do not include CT scans, PET scans, MRI, MRA, nuclear
medicine and major diagnostic 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 may 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 any available
prenatal programs designed to achieve the best outcomes for you and your baby.

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.
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.
COC.CHS.I.11.NJ
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
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 provided include the following:

Screening and diagnostic mammography.

Screening for colorectal cancer as follows:

Annual guaiac-based fecal occult blood test (gFOBT) with high test sensitivity for cancer.

Annual immunochemical-based fecal occult blood test (FIT) with high test sensitivity for
cancer.

Stool DNA (sDNA) test with high test sensitivity for cancer.

S
 creening colonoscopy or Flexible sigmoidoscopy every five years.

Colonoscopy every ten years.

Double contract barium enema every five years.

Computed tomography colonography (virtual colonoscopy) every five years.

A Pap smear including all laboratory costs associated with the Pap smear and any confirmatory
test.

Cervical cancer screening.

Prostate cancer screening which includes an annual diagnostic examination including, but not
limited to, a digital rectal examination and a prostate-specific antigen test for men age 50 and over
who are asymptomatic and for men age 40 and over with a family history of prostate cancer or
other prostate cancer risk factors.

Screening for blood lead measurement for lead poisoning for children. Screening for blood lead
measurement includes confirmatory blood lead testing and medical evaluation and any necessary
medical follow-up and treatment of lead-poisoned children.

Bone mineral density tests.
Health Wellness Exams
Benefits are provided for health wellness examinations which include the following tests and services:

For Covered Persons 20 years of age and older, annual tests to determine blood hemoglobin,
blood pressure, blood glucose level, and blood cholesterol level or, alternatively, low-density
liporotein (LDL) level and blood high-density lipoprotein (HDL) level.

For Covered Persons 35 years of age or older, a glaucoma eye test every five years.

For Covered Persons 40 years of age or older, an annual stool examination for presence of blood.

For Covered Persons 45 years of age or older, a left-sided colon examination of 35 to 60
centimeters every five years.
COC.CHS.I.11.NJ
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
For women 20 years of age or older, a pap smear.

For women who are at least 35 but less than 40, one baseline mammogram examination.

For women 40 years of age or older, a mammogram examination.

For adult Covered Persons, recommended immunizations.

Other tests and services recommended as medically appropriate by a Physician.

For all persons 20 years of age or older, an annual consultation with a Physician to discuss lifestyle
behaviors that promote health and well-being including, but not limited to, smoking control, nutrition
and diet recommendations, exercise plans, lower back protection, weight control, immunization
practices, breast self-examination, testicular self-examination and seat belt usage in motor
vehicles.
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.
Orthotic appliances that straighten or re-shape a body part. For the purpose of this Benefit this refers to a
brace or support but does not include fabric and elastic supports, corsets, arch supports, trusses, elastic
hose, canes, crutches, cervical collars, dental appliances or other similar devices carried in stock and sold
by drug stores, department stores, corset shops or surgical supply facilities.
Benefits under this section are provided only for external prosthetic devices and do not include any device
that is fully implanted into the body other than breast prostheses.
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 who deems
the device to be Medically Necessary and must be obtained from a licensed orthotist or prosthetist, or any
certified pedorthist.
Benefits are available for repairs and replacement if deemed to be Medically Necessary by a Physician.
Reimbursement for these items will be at the same rate as under the federal Medicare reimbursement
schedule.
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 implanted 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.
COC.CHS.I.11.NJ
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Other 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.
Reconstructive procedures include the necessary care and treatment of medically diagnosed congenital
defects and birth abnormalities of newborn children. These procedures that correct an anatomical
Congenial Anomaly are not considered Cosmetic Procedures.
Cosmetic Procedures are excluded from coverage. The fact that a Covered Person may suffer
psychological consequences or socially avoidant behavior as a result of an Injury or Sickness does not
classify surgery (or other procedures done to relieve such consequences or behavior) as a reconstructive
procedure.
31. Rehabilitation Services - Outpatient Therapy and Manipulative Treatment
Short-term outpatient rehabilitation services, limited to:

Physical therapy.

Occupational therapy.

Manipulative Treatment.

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. Benefits can be denied or
shortened for Covered Persons who are not progressing in goal-directed Manipulative Treatment or if
treatment goals have previously been met. Benefits under this section are not available for
maintenance/preventive Manipulative Treatment.
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 Disorders. We will pay Benefits for cognitive
rehabilitation therapy only when Medically Necessary following a post-traumatic brain Injury or cerebral
vascular accident.
Please note that Benefits under this section do not include physical therapy, occupational therapy
or speech therapy for the diagnosis of Autism Spectrum Disorders or other Developmental
Disabilities. Benefits for these services payable as described in Autism Spectrum Disorder and
Other Developmental Disabilities - Rehabilitative Services above.
32. 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.
COC.CHS.I.11.NJ
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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.


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
33. 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:



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:




rehabilitation services or if discharge rehabilitation goals have previously been met.
34. Specialized Non-Standard Infant Formulas
Coverage for specialized non-standard infant formulas when the following conditions are met:
COC.CHS.I.11.NJ
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
The covered infant's Physician has diagnosed the infant as having multiple food protein
intolerance.

The covered infant's Physician has determined specialized non-standard infant formulas to be
Medically Necessary.

The covered infant has not been responsive to trials of standard non-cow milk-based formulas,
including soybean and goat milk.
Benefits are provided to the same extent as for other medical foods as described under the heading
Medical Foods.
35. Substance Use Disorder Services
Substance Use Disorder 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.


Treatment planning.

Referral services.






Special Substance Use Disorder Programs and Services
Designee may become available to you as a part of your Substance Use Disorder Services Benefit. The
Substance Use Disorder 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 use disorder which may not otherwise be covered under the Policy. You must be referred to
such programs through the Mental Health/Substance Use Disorder 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.
COC.CHS.I.11.NJ
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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.


37. 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:

treatment.


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.
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. Benefits are
available for the treatment of Wilms' tumor, including autologous bone marrow transplants when standard
chemotherapy is unsuccessful, even when such treatment is considered Experimental or Investigational.
Treatment of cancer by dose-intensive chemotherapy/autologous bone marrow transplants and peripheral
blood stem cell transplants are a Covered Health Service for which Benefits are payable when performed
at a Provider that is approved by the National Cancer Institute or performed pursuant to protocols
consistent with the guidelines of the American Society of Clinical Oncologists.
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 the Policy.
COC.CHS.I.11.NJ
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Transplantation services must be performed at our Designated Facilities in order to receive an in-Network
level of Benefits. Refer to the Schedule of Benefits for applicable prior authorization requirements. Please
note that not all Network Hospitals are contracted to perform transplants. Please refer to your provider
directory or contact us to find out which hospitals are contracted for this service.
If you reside more than 50 miles from the Designated Facility and are required to travel to obtain
transplantation services from the Designated Facility, we will provide for reimbursement of travel and
lodging expenses for the Covered Person and one companion. Coverage is limited to $50/$100 lodging
per day, up to a maximum Benefit of $10,000 per lifetime. We have specific guidelines regarding Benefits
for transplant services. Contact us at the telephone number on your ID card for information about these
guidelines.
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.
Routine vision examinations, including refraction to detect vision impairment, received from a health care
provider in the provider's office.
Please note that Benefits are not available for charges connected to the purchase or fitting of eyeglasses
or contact lenses.
Benefits for eye examinations required for the diagnosis and treatment of a Sickness or Injury are
provided under Physician's Office Services - Sickness and Injury.
COC.CHS.I.11.NJ
28
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 the Policy.
Benefit Limitations
When Benefits are limited within any of the Covered Health Service categories described in Section 1:
Covered Health Services, those limits are stated in the corresponding Covered Health Service category in
the Schedule of Benefits. Limits may also apply to some Covered Health Services that fall under more
than one Covered Health Service category. When this occurs, those limits are also stated in the Schedule
of Benefits under the heading Benefit Limits. Please review all limits carefully, as we will not pay Benefits
for any of the services, treatments, items or supplies that exceed these Benefit limits.
A. Alternative Treatments
1.
Acupressure and acupuncture.
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 Manipulative
Treatment and non-manipulative osteopathic care for which Benefits are provided as described in
Section 1: Covered Health Services.
B. Dental
1.
Dental care (which includes dental X-rays, supplies and appliances and all associated expenses,
including hospitalizations and anesthesia).
COC.EXC.I.11.NJ
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This exclusion does not apply to accident-related dental services for which Benefits are provided as
described under Dental Services - Accident Only and Dental Services - Other 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 the 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.
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 Dental
Services - Accident Only and Dental Services - Other 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 except for treatment of medically diagnosed congenital birth defects and birth
abnormalities in Dependents that have been covered under the Certificate from the moment of
birth.
C. Devices, Appliances and Prosthetics
1.
Devices used specifically as safety items or to affect performance in sports-related activities.
2.
Cranial banding.
3.
The following items are excluded, even if prescribed by a Physician:

Blood pressure cuff/monitor.

Enuresis alarm.

Non-wearable external defibrillator.

Trusses.

Ultrasonic nebulizers.
COC.EXC.I.11.NJ
30
4.
Devices and computers to assist in communication and speech except for speech aid devices and
tracheo-esophageal voice devices for which Benefits are provided as described under Durable
Medical Equipment in Section 1: Covered Health Services.
5.
Oral appliances for snoring.
6.
Repairs to prosthetic devices due to misuse, malicious damage or gross neglect.
7.
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. This
exclusion does not apply to oral agents for controlling blood sugar or to medications used to treat
infertility for which Benefits are provided as described under Diabetes Services and Infertility
Services in Section 1: Covered Health Services.
2.
Self-injectable medications except as described under the heading Diabetes Services in Section 1:
Covered Health Services. 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.
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. This exclusion does not apply to diabetic supplies for
which Benefits are provided as described under Diabetes Services in Section 1: Covered Health
Services.
5.
Growth hormone therapy.
6.
Benefits for Pharmaceutical Products for the amount dispensed (days' supply or quantity limit)
which exceeds the supply limit.
7.
New Pharmaceutical Products and/or new dosage forms until the date they are assigned to a tier
by our Pharmaceutical Product List Management Committee.
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 or to
the treatment for Wilm's tumor as described under Transplantation Services 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.
COC.EXC.I.11.NJ
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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.
Arch supports.
G. Medical Supplies
1.
Prescribed or non-prescribed medical supplies and disposable supplies. Examples include:

Compression stockings.

Ace bandages.

Gauze and dressings.

Urinary catheters.
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

Ostomy supplies for which Benefits are provided as described under Ostomy Supplies in
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
Exclusions listed directly below apply to services described under Mental Health Services in Section 1:
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 V-code conditions as listed within the current edition of
the Diagnostic and Statistical Manual of the American Psychiatric Association.
3.
Mental Health Services as treatment for a primary diagnosis of insomnia and other sleep disorders,
sexual dysfunction disorders, feeding disorders, neurological disorders and other disorders with a
known physical basis.
4.
Treatments for the primary diagnoses of learning disabilities, conduct and impulse control
disorders, personality disorders and paraphilias.
COC.EXC.I.11.NJ
32
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 skills and primary communication disorders as defined in the current edition of the
8.
Mental retardation 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 Neurobiological Disorders
- Autism Spectrum Disorder Services in Section 1: Covered Health Services.
9.
Services or supplies for the diagnosis or treatment of Mental Illness that, in the reasonable
judgment of the Mental Health/Substance Use Disorder Designee, are any of the following:

Not consistent with Generally Accepted Standards of Medical Practice for the treatment of
such conditions.

Not consistent with services backed by credible research soundly demonstrating that the
services or supplies will have a measurable and beneficial health outcome.

Not consistent with the Mental Health/Substance Use Disorder Designee's level of care
guidelines or best practices as modified from time to time.

Not clinically appropriate for the patient's Mental Illness or condition based on Generally
Accepted Standards of Medical Practice and benchmarks.
If you are dissatisfied with the decision of the Mental Health/Substance Use Disorder Designee, you have
the right to appeal. Please refer to Section 6: Questions, Complaints and Appeals for appeals process
and procedures.
I. Neurobiological Disorders - Autism Spectrum Disorders
Exclusions listed directly below apply to services described under Neurobiological 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.
3.
Mental retardation as the primary diagnosis defined in the current edition of the Diagnostic and
Statistical Manual of the American Psychiatric Association.
4.
5.
Diagnostic and Statistical Manual of the American Psychiatric Association and which are not a part
of Autism Spectrum Disorder.
6.
7.
Services or supplies for the diagnosis or treatment of Autism Spectrum Disorder that, in the
reasonable judgment of the Mental Health/Substance Use Disorder Designee, are any of the
following:
COC.EXC.I.11.NJ
33

such conditions.



Not clinically appropriate for the patient's Autism Spectrum Disorder or condition based on
Generally Accepted Standards of Medical Practice and benchmarks.
and procedures.
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.
3.
Infant formula and donor breast milk except as provided under Medical Foods and Specialized
Non-Standard Infant Formulas in Section 1: Covered Health Services.
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.

Car seats.

Chairs, bath chairs, feeding chairs, toddler chairs, chair lifts and recliners.

Exercise equipment.
COC.EXC.I.11.NJ
34

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.

Whirlpools.
L. Physical Appearance
1.
Cosmetic Procedures. See the definition in Section 9: 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.
We pay Benefits for the necessary care and treatment of medically diagnosed congenital defects
and birth abnormalities of newborn children.
COC.EXC.I.11.NJ
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2.
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:
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 regardless of the reason for the hair loss.
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.
Speech therapy except as required for treatment of a speech impediment or speech dysfunction
that results from Injury, stroke, cancer, Congenital Anomaly, or Autism Spectrum Disorders.
5.
Outpatient cognitive rehabilitation therapy except as Medically Necessary following a posttraumatic brain Injury or cerebral vascular accident.
6.
Psychosurgery.
7.
Sex transformation operations and related services.
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.
10.
Services for the evaluation and treatment of temporomandibular joint syndrome (TMJ), whether the
services are considered to be medical or dental in nature.
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:
COC.EXC.I.11.NJ
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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 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.
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.
2.
Surrogate parenting.
3.
The reversal of voluntary sterilization.
P. Services Provided under another Plan
1.
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, or similar legislation.
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.
3.
Health services for treatment of military service-related disabilities:

as a result of war or an act of war, if the illness or Injury occurs while you are serving in the
military, naval or air forces of any country, combination of countries or international
organization; and

as a result of the special hazards incident to service in the military, naval or air forces of any
country, combination of countries or international organization, if the illness or Injury occurs
while you are serving in such forces and are outside the United States and Canada.
Health services while on active military duty:

organization; and
COC.EXC.I.11.NJ
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
Q. Substance Use Disorders
Exclusions listed directly below apply to services described under Substance Use Disorder Services in
1.
2.
Methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol), Cyclazocine, or their
equivalents.
3.
4.
Services or supplies for the diagnosis or treatment of alcoholism or substance use disorders that, in
the reasonable judgment of the Mental Health/Substance Use Disorder Designee, are any of the
following:

such conditions.

services or supplies will have a measurable and beneficial health outcome, and therefore
considered experimental/investigational or unproven.


Not clinically appropriate for the patient's substance use disorder or condition based on
If you are dissatisfied with the decision of the Mental Health/Substance Use Disorder Designee,
you have the right to appeal. Please refer to Section 6: Questions, Complaints and Appeals for
appeals process and procedures.
R. Transplants
1.
Health services for organ and tissue transplants, except those described under Transplantation
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 the Policy.)
3.
Health services for transplants involving permanent mechanical or animal organs.
4.
Transplant services that are not performed at a Designated Facility will not be paid on an inNetwork basis. Non-Network Benefits will apply, if applicable. This exclusion does not apply to
cornea transplants.
5.
cornea transplants.
COC.EXC.I.11.NJ
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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 at our discretion. Refer to Transplantation Services in Section 1: Covered
Health Services for more information. This exclusion does not apply to ambulance transportation
for which Benefits are provided as described under Ambulance Services in Section 1: Covered
Health Services.
T. Types of Care
1.
Multi-disciplinary pain management programs provided on an inpatient basis for acute pain or for
exacerbation of chronic pain.
2.
Custodial Care or maintenance care regardless of whether provided in a home setting or in a
facility.
3.
Private Duty Nursing.
4.
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.
5.
Rest cures.
6.
Services of personal care attendants.
7.
Work hardening (individualized treatment programs designed to return a person to work or to
prepare a person for specific work).
U. Vision and Hearing
1.
Purchase cost and fitting charge for eyeglasses and contact lenses.
2.
Implantable lenses used only to correct a refractive error (such as Intacs corneal implants).
3.
Eye exercise or vision therapy.
4.
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.
5.
Bone anchored hearing aids except when either of the following applies:

For Covered Persons with craniofacial anomalies whose abnormal or absent ear canals
preclude the use of a wearable hearing aid.

For Covered Persons with hearing loss of sufficient severity that it would not be adequately
remedied by a wearable hearing aid.
More than one bone anchored hearing aid per Covered Person who meets the above coverage
criteria during the entire period of time the Covered Person is enrolled under the Policy.
Repairs and/or replacement for a bone anchored hearing aid for Covered Persons who meet the
above coverage criteria, other than for malfunctions.
COC.EXC.I.11.NJ
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V. All Other Exclusions
1.
2.
3.
Health services and supplies that do not meet the definition of a Covered Health Service - see the
definition in Section 9: Defined Terms. Covered Health Services are 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 Certificate under Section 1: Covered Health
Services and in the Schedule of Benefits.

Not otherwise excluded in this Certificate under Section 2: Exclusions and Limitations.
Physical, psychiatric or psychological exams, testing, vaccinations, immunizations or treatments
that are otherwise covered under the 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.

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.
Health services received as a result of war or any act of war:

as a result of war or an act of war, if the illness or Injury occurs while you are serving in any
civilian non-combatant unit supporting or accompany any military, naval or air forces of any
country, combination of countries or international organization; and

as a result of the special hazards incident to service in any civilian non-combatant unit
supporting or accompanying such forces, provided the illness or Injury occurs while you are
serving in such unit and are outside the United States and Canada.
Health services received as a result of war or any act of war while you are not in the military, naval
or air forces of any country, combination of countries or international organization or in any civilian
non-combatant unit supporting or accompanying such forces, if the illness or Injury occurs outside
the United States and Canada.
4.
Health services received after the date your coverage under the 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 the 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 the 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.
COC.EXC.I.11.NJ
40
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.
COC.EXC.I.11.NJ
41
Section 3: When Coverage Begins
How to Enroll
Eligible Persons must complete an enrollment form. The Enrolling Group will give the necessary forms to
you. The Enrolling Group will then submit the completed forms to us, along with any required Premium.
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 the Policy. These Benefits will be paid by us unless they are being paid by a
prior carrier under such prior carrier's obligations with respect to extension of benefits 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. For Benefit plans that have a Network Benefit level, Network Benefits are
available only if you receive Covered Health Services from Network providers unless rendered to treat an
Emergency as described in the Emergency Services Benefit of the Covered Health Services section.
Covered Health Services received in accordance with the Emergency Services Benefit will be treated as
Network Benefits regardless of whether the services were rendered by a Network or a non-Network
provider.
Who is Eligible for Coverage
The Enrolling Group determines who is eligible to enroll under the Policy and who qualifies as a
Dependent. Please contact the Benefits Administrator of the Group for information on who they have
determined is eligible to enroll under this Policy.
Eligible Person
Eligible Person usually refers to an employee or member of the Enrolling Group who meets the eligibility
rules. When an Eligible Person actually enrolls, we refer to that person as a Subscriber. For a complete
definition of Eligible Person, Enrolling Group and Subscriber, see Section 9: Defined Terms.
Eligible Persons must reside within the United States.
If both spouses are Eligible Persons of the Enrolling Group, each may enroll as a Subscriber or be
covered as an Enrolled Dependent of the other, but not both.
Dependent
Dependent generally refers to the Subscriber'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 9: Defined Terms.
Dependents of an Eligible Person may not enroll unless the Eligible Person is also covered under the
Policy.
The term spouse also includes Civil Union Partners as defined by, and in accordance with New Jersey
law and the valid laws of another jurisdiction under which a civil union relationship was created.
COC.BGN.I.11.NJ
42
If both parents of a Dependent child are enrolled as a Subscriber, only one parent may enroll the child as
a Dependent.
For a description of the State of New Jersey Continuation for Over-Age Dependents, see Section 4:
When Coverage Ends.
When to Enroll and When Coverage Begins
Except as described below, Eligible Persons may not enroll themselves or their Dependents.
Initial Enrollment Period
When the Enrolling Group purchases coverage under the Policy from us, the Initial Enrollment Period is
the first period of time when Eligible Persons can enroll themselves and their Dependents.
Coverage begins on the date identified in the Policy if we receive the completed enrollment form and any
required Premium within 31 days of the date the Eligible Person becomes eligible to enroll.
Open Enrollment Period
The Enrolling Group determines the Open Enrollment Period. During the Open Enrollment Period, Eligible
Persons can enroll themselves and their Dependents.
Coverage begins on the date identified by the Enrolling Group if we receive the completed enrollment
form and any required Premium within 31 days of the date the Eligible Person becomes eligible to enroll.
Dependent Child Special Open Enrollment Period
On or before the first day of the first plan year beginning on or after September 23, 2010, the Enrolling
Group will provide a 30 day dependent child special open enrollment period for Dependent children who
are not currently enrolled under the Policy and who have not yet reached the limiting age. During this
dependent child special open enrollment period, Subscribers who are adding a Dependent child and who
have a choice of coverage options will be allowed to change options.
Coverage begins on the first day of the plan year beginning on or after September 23, 2010, if we receive
the completed enrollment form and any required Premium within 31 days of the date the Dependent
becomes eligible to enroll under this special open enrollment period.
New Eligible Persons
Coverage for a new Eligible Person and his or her Dependents begins on the date agreed to by the
Enrolling Group if we receive the completed enrollment form and any required Premium within 31 days of
the date the new Eligible Person first becomes eligible.
Adding New Dependents
Subscribers may enroll Dependents who join their family because of any of the following events:

Birth. Coverage for a newborn child begins at the moment of birth and continues for 31 days as if
the child were enrolled, without additional Premium for these 31 days.

Legal adoption.

Placement for adoption.

Marriage or civil union.
COC.BGN.I.11.NJ
43

Legal guardianship.

Court or administrative order.

Registering a Domestic Partner. Only persons age 62 and older are permitted to enter into a
Domestic Partnership in the State of New Jersey as of February 19, 2007.
Coverage for the Dependent begins on the date of the event if we receive the completed enrollment form
and any required Premium within 31 days of the event that makes the new Dependent eligible.
Special Enrollment Period
An Eligible Person and/or Dependent may also be able to enroll during a special enrollment period. A
special enrollment period is not available to an Eligible Person and his or her Dependents if coverage
under the prior plan was terminated for cause, or because premiums were not paid on a timely basis.
An Eligible Person and/or Dependent does not need to elect COBRA continuation coverage to preserve
special enrollment rights. Special enrollment is available to an Eligible Person and/or Dependent even if
COBRA is not elected.
A special enrollment period applies to an Eligible Person and any Dependents when one of the following
events occurs:

Birth.

Legal adoption.



A special enrollment period also applies for an Eligible Person and/or Dependent who did not enroll
during the Initial Enrollment Period or Open Enrollment Period if the following are true:

The Eligible Person previously declined coverage under the Policy, but the Eligible Person and/or
Dependent becomes eligible for a premium assistance subsidy under Medicaid or Children's Health
Insurance Program (CHIP). Coverage will begin only if we receive the completed enrollment form
and any required Premium within 60 days of the date of determination of subsidy eligibility.

The Eligible Person and/or Dependent had existing health coverage under another plan at the time
they had an opportunity to enroll during the Initial Enrollment Period or Open Enrollment Period;
and

Coverage under the prior plan ended because of any of the following:

Loss of eligibility (including legal separation, divorce, dissolution of a civil union, dissolution
of Domestic Partnership or Life Partnership or death).

The employer stopped paying the contributions. This is true even if the Eligible Person
and/or Dependent continues to receive coverage under the prior plan and to pay the
amounts previously paid by the employer.

In the case of COBRA continuation coverage, the coverage ended.

The Eligible Person and/or Dependent no longer lives or works in an HMO service area if no
other benefit option is available.
COC.BGN.I.11.NJ
44

The plan no longer offers benefits to a class of individuals that include the Eligible Person
and/or Dependent.

An Eligible Person and/or Dependent incurs a claim that would exceed a lifetime limit on all
benefits.

The Eligible Person and/or Dependent loses eligibility under Medicaid or Children's Health
Insurance Program (CHIP). Coverage will begin only if we receive the completed enrollment
form and any required Premium within 60 days of the date coverage ended.
When an event takes place (for example, a birth, marriage or determination of eligibility for state subsidy),
coverage begins on the date of the event if we receive the completed enrollment form and any required
Premium within 31 days of the event unless otherwise noted above.
For an Eligible Person and/or Dependent who did not enroll during the Initial Enrollment Period or Open
Enrollment Period because they had existing health coverage under another plan, coverage begins on
the day immediately following the day coverage under the prior plan ends. Except as otherwise noted
above, coverage will begin only if we receive the completed enrollment form and any required Premium
within 31 days of the date coverage under the prior plan ended.
COC.BGN.I.11.NJ
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Section 4: When Coverage Ends
General Information about When Coverage Ends
We may discontinue this Benefit plan and/or all similar benefit plans for the reasons explained in the
Policy, as permitted by law.
Unless you are entitled to Extended Coverage for Total Disability, your entitlement to Benefits
automatically ends on the date that coverage ends, even if you are otherwise receiving medical treatment
on that date. Please note that this does not affect coverage that is extended under Extended Coverage
for Total Disability below.
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). Please note that this does not affect coverage that is extended
under Extended Coverage for Total Disability below.
Unless otherwise stated, an Enrolled Dependent's coverage ends on the date the Subscriber's coverage
ends.
Events Ending Your Coverage
Coverage ends on the earliest of the dates specified below:

The Entire Policy Ends
Your coverage ends on the date the Policy ends. In the event the entire Policy ends, the Enrolling
Group is responsible for notifying you that your coverage has ended.

You Are No Longer Eligible
Your coverage ends on the date you are no longer eligible to be a Subscriber or Enrolled
Dependent. Please refer to Section 9: Defined Terms for complete definitions of the terms "Eligible
Person," "Subscriber," "Dependent" and "Enrolled Dependent". You must notify us when a child no
longer meets the requirements for Dependent coverage. If we are not notified, the Subscriber must
reimburse us for any Benefits that we pay for a child at a time when the child did not satisfy these
conditions. Refer to the definition of "Dependent" in Section 9: Defined Terms for requirements of
Dependent coverage.

We Receive Notice to End Coverage
Your coverage ends on the date we receive written notice from the Enrolling Group instructing us to
end your coverage, or the date requested in the notice, if later. The Enrolling Group is responsible
for providing written notice to us to end your coverage.

Subscriber Retires or Is Pensioned
Your coverage ends the date the Subscriber is retired or receiving benefits under the Enrolling
Group's pension or retirement plan. The Enrolling Group is responsible for providing written notice
to us to end your coverage.
This provision applies unless a specific coverage classification is designated for retired or
pensioned persons in the Enrolling Group's application, and only if the Subscriber continues to
meet any applicable eligibility requirements. The Enrolling Group can provide you with specific
information about what coverage is available for retirees.
COC.END.I.11.NJ
46
Other Events Ending Your Coverage
We will provide 30 days advance written notice to the Subscriber of a Rescission of coverage and that
coverage will end on the date we identify in the notice if any form of fraud or intentional misrepresentation
of a material fact.
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 false information relating to another person's eligibility or status as a
Dependent.
During the first two years the Policy is in effect, 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. In this case, we will also refund the Premiums that were paid to us for your coverage. After the first
two years, we can only demand that you pay back these Benefits if the written application contained a
fraudulent misstatement.
Coverage for a Disabled Dependent Child
Coverage for an unmarried Enrolled Dependent child who is not able to be self-supporting because of
mental retardation or a physical handicap 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 retardation or physical handicap or disability.

Depends mainly on the Subscriber for support.
Coverage will continue as long as the Enrolled Dependent is incapacitated and dependent unless
coverage is otherwise terminated in accordance with the terms of the Policy.
We will ask you to furnish us with proof of the incapacity and dependency 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 incapacity and dependency within 31 days of our request as
described above, coverage for that child will end.
Extended Coverage for Total Disability
Coverage for a Covered Person who is Totally Disabled on the date the entire Policy is terminated will not
end automatically. We will temporarily extend the coverage, only for treatment of the condition causing
the Total Disability. Benefits will be paid until the earlier of either of the following:

The Total Disability ends.

Twelve months from the date coverage would have ended when the entire Policy was terminated.

The date maximum Benefits under the Policy have been received.
COC.END.I.11.NJ
47
Continuation of Coverage and Conversion
If your coverage ends under the Policy, you may be entitled to elect continuation coverage (coverage that
continues on in some form) in accordance with federal or state law.
Continuation coverage under COBRA (the federal Consolidated Omnibus Budget Reconciliation Act) is
available only to Enrolling Groups that are subject to the terms of COBRA. You can contact your plan
administrator to determine if your Enrolling Group is subject to the provisions of COBRA.
If you selected continuation coverage under a prior plan which was then replaced by coverage under the
Policy, continuation coverage will end as scheduled under the prior plan or in accordance with federal or
state law, whichever is earlier.
We are not the Enrolling Group's designated "plan administrator" as that term is used in federal law, and
we do not assume any responsibilities of a "plan administrator" according to federal law.
We are not obligated to provide continuation coverage to you if the Enrolling Group or its plan
administrator fails to perform its responsibilities under federal law. Examples of the responsibilities of the
Enrolling Group or its plan administrator are:

Notifying you in a timely manner of the right to elect continuation coverage.

Notifying us in a timely manner of your election of continuation coverage.
Continuation Coverage under Federal Law (COBRA)
Much of the language in this section comes from the federal law that governs continuation coverage. You
should call your Enrolling Group's plan administrator if you have questions about your right to continue
coverage.
In order to be eligible for continuation coverage under federal law, you must meet the definition of a
"Qualified Beneficiary". A Qualified Beneficiary is any of the following persons who was covered under the
Policy on the day before a qualifying event:

An employee (also referred to as "Subscriber").

An Enrolled Dependent spouse of a Subscriber

An Enrolled Dependent child of the Subscriber. NOTE: If a covered Subscriber has a new child or
adopts a new child during the continuation period, such new child will also be treated as a Qualified
Beneficiary.
Per federal law, Civil Union Partners, Domestic Partners or Life Partners and their Eligible Dependents
are prohibited from obtaining COBRA continuation.
Qualifying Events for Continuation Coverage under Federal Law (COBRA)
The events listed below constitute “Qualifying Events” under COBRA. This means that if such event
occurs and results in a loss of coverage to the Qualified Beneficiary under the group health plan the
Qualified Beneficiary may be entitled to continue coverage for a certain period of time beyond the normal
termination date. In order to continue coverage under this section, the appropriate Premium contributions
must be made by (or on behalf of) the Qualified Beneficiary. Terminating Events for Continuation
Coverage under Federal Law (COBRA) to determine the length of the continuation period). The
Qualifying Events for an employee are as follows:
A. For Subscribers, the termination of employment with the Enrolling Group (termination can be
voluntary or involuntary but, if involuntary must be for any reason(s) other than gross misconduct),
or loss of coverage as a result of a reduction of hours; or
COC.END.I.11.NJ
48
B. For Enrolled Dependents, the death of the Subscriber; or
C. For the Enrolled Dependent spouse, the divorce or legal separation from the Subscriber; or
D. For the Enrolled Dependent children, the loss of eligibility under the terms of the group health
plan (e.g., reaching the maximum age); or
E. For Enrolled Dependents, the Subscriber's entitlement to Medicare benefits that results in a loss
of coverage for the Enrolled Dependents.
NOTE: Special rules apply for Enrolling Groups filing for bankruptcy, under Title XI, United States
Code. Please contact your Enrolling Group's plan administrator for additional details regarding
COBRA rights in the event of bankruptcy.
Notification Requirements and Election Period for Continuation Coverage under
Federal Law (COBRA)
The Subscriber or other Qualified Beneficiary must notify the Enrolling Group's designated plan
administrator within 60 days of the Subscriber's divorce, legal separation or an Enrolled Dependent's loss
of eligibility as an Enrolled Dependent. If the Subscriber or other Qualified Beneficiary fails to notify the
designated plan administrator of these events within the 60 day period, the Enrolling Group and its plan
administrator are not obligated to provide continued coverage to the affected Qualified Beneficiary. If a
Subscriber is continuing coverage under federal law, the Subscriber must notify the Enrolling Group's
designated plan administrator within 60 days of the birth or adoption of a child.
Continuation must be elected by the later of 60 days after the qualifying event occurs; or 60 days after the
Qualified Beneficiary receives notice of the continuation right from the Enrolling Group's designated plan
administrator.
If the Qualified Beneficiary's coverage was terminated due to a qualifying event, then the initial Premium
due to the Enrolling Group's designated plan administrator must be paid on or before the 45th day after
electing continuation.
Terminating Events for Continuation Coverage under Federal Law (COBRA)
Continuation under the Policy will end on the earliest of the following dates:
A. Eighteen months from the date of the qualifying event, if the Qualified Beneficiary's coverage
would have ended because the Subscriber's employment was terminated or hours were reduced
(i.e., qualifying event A.).
If a Qualified Beneficiary is determined to have been disabled under the Social Security Act at
anytime within the first 60 days of continuation coverage for qualifying event A. then the Qualified
Beneficiary may elect an additional 11 months of continuation coverage (for a total of 29 months of
continued coverage) subject to the following condition: (i) notice of such disability must be provided
within 60 days after the determination of the disability, and in no event later than the end of the first
18 months; (ii) the Qualified Beneficiary must agree to pay any increase in the required Premium
for the additional 11 months; and (iii) if the Qualified Beneficiary entitled to the 11 months of
coverage has non-disabled family members who are also Qualified Beneficiaries, then those nondisabled Qualified Beneficiaries are also entitled to the additional 11 months of continuation
coverage. Notice of any final determination that the Qualified Beneficiary is no longer disabled must
be provided within 30 days of such determination. Thereafter, continuation coverage may be
terminated on the first day of the month that begins more than 30 days after the date of that
determination.
COC.END.I.11.NJ
49
B. Thirty-six months from the date of the qualifying event for an Enrolled Dependent whose
coverage ended because of the death of the Subscriber, divorce or legal separation of the
Subscriber, loss of eligibility by an Enrolled Dependent who is a child (i.e. qualifying events B., C.,
or D).
C. For the Enrolled Dependents of a Subscriber who was entitled to Medicare prior to a qualifying
event that was due to either the termination of employment or work hours being reduced, eighteen
months from the date of the qualifying event, or, if later, 36 months from the date of the
Subscriber's Medicare entitlement. For Enrolled Dependents of a Subscriber who becomes eligible
for Medicare after the Subscriber’s qualifying event due to either termination of employment or
reduction in work hours, may be entitled to 36 months of continuation coverage from the date of the
Subscriber’s first qualifying event (subject to certain group health plan restrictions).
D. The date coverage terminates under the Policy for failure to make timely payment of the
Premium.
E. The date, after electing continuation coverage, that coverage is first obtained under any other
group health plan. If such coverage contains a limitation or exclusion with respect to any preexisting condition, continuation shall end on the date such limitation or exclusion ends. The other
group health coverage shall be primary for all health services except those health services that are
subject to the pre-existing condition limitation or exclusion.
F. The date, after electing continuation coverage, that the Qualified Beneficiary first becomes
entitled to Medicare, except that this shall not apply in the event that coverage was terminated
because the Enrolling Group filed for bankruptcy, (i.e. qualifying event F.)
G. The date the entire Policy ends.
H. The date coverage would otherwise terminate under the Policy as described in this section
under the heading Events Ending Your Coverage.
If a Qualified Beneficiary is entitled to 18 months of continuation and a second qualifying event occurs
during that time, the Qualified Beneficiary's coverage may be extended up to a maximum of 36 months
from the date coverage ended because employment was terminated or hours were reduced. If the
Qualified Beneficiary was entitled to continuation because the Enrolling Group filed for bankruptcy, (i.e.
qualifying event F) and the retired Subscriber dies during the continuation period, then the other Qualified
Beneficiaries shall be entitled to continue coverage for 36 months from the date of the Subscriber's death.
Terminating events B through G described in this section will apply during the extended continuation
period.
Continuation coverage for Qualified Beneficiaries whose continuation coverage terminates because the
Subscriber becomes entitled to Medicare may be extended for an additional period of time (see section
"C" above). Such Qualified Beneficiaries should contact the Enrolling Group's designated plan
administrator for information regarding the continuation period.
New Jersey Continuation Rights for Over-Age Dependents (NJCROD)
A dependent who has elected to continue his or her coverage under the group policy under which his or
her parent is currently covered pursuant to NJCROD shall not be entitled to further continue coverage
under COBRA when continuation pursuant to NJCROD ends. As used in this provision, "Over-Age
Dependent" means an Employee's child by blood or law who:

Has reached the limiting age as described in this Certificate of Coverage, under Section 10:
Definitions, but is less than 31 years of age;

Is not married or part of a civil union or part of a domestic partnership;

Has no Dependents of his or her own;
COC.END.I.11.NJ
50

Is either a resident of New Jersey or in enrolled as a Full-time Student at an accredited school; and

Is not covered under any other group or individual health benefits plan, group health plan, church
plan, or health benefits plan, and is not entitled to Medicare.
Eligibility for Continuation through NJCROD
If a Dependent child's group health benefits end or have ended due to his or her attainment of the limiting
age described in this Certificate of Coverage, he or she may elect to continue such benefits until his or
her 31st birthday, subject to the Conditions for Election, Election of Continuation and When Continuation
Ends sections below.
Conditions for Election - An Over-Age Dependent is only entitled to make an election for continued
coverage if all of the following conditions are met:

The Over-Age-Dependent must provide evidence of prior creditable coverage or receipt of benefits
under a group or individual health benefits plan, group health plan, church plan or health benefits
plan or Medicare. Such prior coverage must have been in effect on the date the Over-AgeDependent reached the limiting age, or at any time after such date but prior to making an election
for this Over-Age-Dependent coverage.

The Subscriber of an Over-Age Dependent must be enrolled as having elected Dependent
coverage at the time the Over-Age Dependent elects continued coverage. Except, if the employee
has no other Dependents, or has a spouse who is covered elsewhere, the Over-Age-Dependent
may nevertheless select continued coverage.
Election of Continuation - To continue health benefits, the Over-Age Dependent must make written
election to us. The effective date of the continued coverage will be the later of:

The date the Over-Age Dependent gives written notice to us;

The date the Over-Age Dependent pays the first premium; or

The date the Dependent would otherwise lose coverage due to the attainment of the limiting age.
For a Dependent whose coverage has not yet terminated due to reaching the limiting age stated in this
Certificate of Coverage, Section 9: Defined Terms - Dependent, the written election must be made within
30 days prior to termination of coverage due to the attainment of the limiting age.
For a person who did not qualify as an Over-Age Dependent because he or she fails to meet all the
requirements of an Over-Age Dependent, but who subsequently meets all of the requirements for an
Over-Age Dependent, written election must be made within 30 days after the person first subsequently
meets all of the requirements for an Over-Age Dependent.
This election opportunity is explained in greater detail as follows:

If a person did not qualify because he or she was married or part of a civil union, the notice must be
given within 30 days of the date he or she is no longer married.

If a person did not qualify because he or she had a Dependent of his or her own, the election must
be made within 30 days of the date her or she no longer has a Dependent.

If a person did not qualify because he or she either was not a resident of New Jersey or was not a
Full-time student at an accredited school, the election must be made within 30 days of the date he
or she becomes a resident a New Jersey, or becomes a Full-time Student at an accredited school.

If a person did not qualify because he or she was covered under an other group or individual health
benefits plan, group health plan, church plan or health benefits plan, or was entitled to Medicare,
the election must be made within 30 days of the date he or she is no longer covered under any
other group or individual health benefits plan, group health plan, church plan or health benefits
plan, or is no longer entitled to Medicare.
COC.END.I.11.NJ
51
Each year there will be an Open Enrollment Period during which an Over-Age Dependent, who previously
did not elect to continue coverage, may make an election to continue coverage. A group Open Enrollment
Period will be held at least annually.
Application of a Pre-Existing Conditions Exclusion
An Over-Age Dependent who was covered under prior creditable coverage that terminated no more than
90 days prior to making an election for continuation under this section will be given credit for the time he
or she was covered under the credible coverage toward the application of the Pre-Existing Conditions
Exclusion under the Policy.
Premium Payments
The first month's Premium must be paid within 30 days of the date the Over-Age Dependent elects
continued coverage.
The Over-Age Dependent must pay subsequent Premiums monthly, in advance, at the times and in the
manner specified by us. The monthly Premium will be set by us, and must be consistent with the
requirements of P.L. 2005, c.375.
Continued Benefits
The continued benefits shall be identical to the coverage provided to the Over-Age Dependent's
Subscriber who is covered as an Employee under the Policy. If coverage is modified for Dependents who
are under the limiting age, the coverage for Over-Age Dependent's Subscriber who is covered as an
employee under the Policy. If coverage is modified for Dependents who are under the limiting age, the
coverage for Over-Age Dependents shall also be modified in the same manner. Evidence of insurability is
not required for the continued coverage.
When Continuation Ends
An Over-Age Dependent's continued group health benefits end on the first of the following:

The date the Over-Age Dependent:

Attains age 31;

Marries or enters a civil union;

Acquires a Dependent;

Is no longer either a resident of New Jersey or enrolled as a Full-time Student at an
accredited school; or

Becomes covered under any other group or individual health benefits plan, group health
plan, church plan or health benefits plan, or becomes entitled to Medicare.

The end of the period for which Premium has been paid for the Over-Age Dependent, subject to
the grace period for such payment;

The date the Policy ceases to provide coverage to the Over-Age Dependent's Subscriber who is
the employee under the Policy.

The date the Policy under which the Over-Age Dependent elected to continue coverage is
amended to delete coverage for Dependents.

The date the Over-Age Dependent's Subscriber who is covered as an Employee under the Policy
waives Dependent coverage. Except if the Subscriber has no other Dependents, the Over-Age
Dependent's coverage will not end as a result of the Subscriber waiving Dependent coverage.
COC.END.I.11.NJ
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State Continuation of Coverage for Totally Disabled Subscribers
If a Subscriber's coverage stops because his or her employment ends and the Subscriber meets the
conditions shown below, the Subscriber may choose to continue the coverage then in effect. The
Subscriber must meet the following conditions:

The Subscriber's employment ended because he or she is Totally Disabled.

The Subscriber must have been covered under the Policy for at least three months before his or
her coverage would have stopped.

The Subscriber must choose to continue coverage within 31 days after the date his or her coverage
would have stopped.

The Subscriber will have to make payments to the Enrolling Group for the coverage.
Coverage will stop on the earliest of the following:

The date the Subscriber becomes employed and eligible for another plan of group health coverage.

The date coverage ends for failure to make timely payment of the Premium.

The date the Policy ends.
"Totally Disabled" for the purpose of this state continuation means the Subscriber's complete inability due
to Injury or Sickness to engage in any and every gainful occupation for which the Subscriber is or
becomes reasonably fitted by education, training or experience and that the Subscriber is not engaged in
any gainful occupation.
Optional State Continuation of Coverage After the Subscriber's Death
If the Subscriber dies while covered, his or her Dependents' coverage may continue. It will continue with
the same benefits and provisions that the Subscriber's Dependents had while the Subscriber was alive. It
will continue only while the Policy is in force. It will stop on the earlier of the following:

The date of the Subscriber's widow's or widower's death, or the date the last child stops being an
eligible Dependent, whichever happens later.

180 days after the date of the Subscriber's death.
The Subscriber's Dependents will have to make payments to the Enrolling Group for the coverage.
After the Subscriber's widow's or widower's death, coverage for the Subscriber's Dependent children may
be continued. It will continue with the same Benefits and provisions that the Subscriber's Dependents had
while the Subscriber's widow or widower was alive. It will continue according to the rules and time limits
described above.
Conversion
If your coverage terminates for one of the reasons described below, you may apply for conversion
coverage without furnishing evidence of insurability.
Reasons for termination:

The Subscriber is retired or pensioned.

You cease to be eligible as a Subscriber or Enrolled Dependent.

Continuation coverage ends.
COC.END.I.11.NJ
53

The entire Policy ends and is not replaced.
If your marriage or civil union is dissolved, the Subscriber's former spouse may buy conversion coverage.
The conversion coverage will be an individual policy. The Subscriber's former spouse may apply for
conversion coverage at either of the following times:

The date the marriage or civil union is dissolved.

At the end of any period of continuation of coverage under the Policy, but only if the Policy is in
force on that date.
Application and payment of the initial Premium must be made within 31 days after coverage ends under
the Policy. Conversion coverage will be issued in accordance with the terms and conditions in effect at
the time of application. Conversion coverage may be substantially different from coverage provided under
the Policy.
COC.END.I.11.NJ
54
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, if you make an assignment of
Benefits, the non-Network provider is responsible for requesting payment from us. The non-Network
provider must file the claim on the standard claim form prescribed by New Jersey that contains all of the
information we require, as described below. At your option, you may also submit the claim to us directly.
Your non-Network provider should submit a request for payment of Benefits within 60 days after the date
of service. If you have assigned benefits to the non-Network provider, as described below, the nonNetwork provider should submit a request for payment of Benefits within 180 days after the date of
service. If this information is not provided to us within one year of the date of service, Benefits for that
health service will be denied or reduced, subject to the appeal provisions in Section 6, Questions,
Complaints and Appeals. This time limit does not apply if it was not reasonably possible to submit the
request in the time required and the request was submitted as soon as reasonably possible. If your claim
relates to an Inpatient Stay, the date of service is the date your Inpatient Stay ends.
Required Information
When you request payment of Benefits from us, We will provide you with the appropriate forms to submit
proof of loss. You must submit the completed form to us with all of the following information:

The Subscriber'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.
If you do not receive the forms for proof of loss within 15 days of our receipt of notice of a claim, you may
submit written proof of loss describing the occurrence, character and extent of the loss for which the claim
is being made.
COC.CLM.I.11.NJ
55
Payment of Benefits
We will pay Benefits within the time frames shown below after we receive a request for payment that
includes all required information.

30 days after we receive a request submitted by electronic means.

40 days after we receive a request submitted by other than electronic means.
Requests for payment that include all required information which are not paid within these time frames will
include an overdue payment of simple interest at the rate of 12% per annum.
If a Subscriber provides written authorization to allow this, all or a portion of any Eligible Expenses due to
a provider will be paid directly to the provider instead of being paid to the Subscriber. But we will not
reimburse third parties that have purchased or been assigned benefits by Physicians or other providers.
Benefits will be paid to you unless either of the following is true:

The provider notifies us that your signature is on file, assigning benefits directly to that provider.

You make a written request at the time you submit your claim.
When an assignment is not obtained, we will send the reimbursement directly to you (the Subscriber) for
you to reimburse them upon receipt of their bill. We will, however, pay a non-Network provider directly for
services rendered to you if you provide written authorization to allow this. In the case of any such
assignment of Benefits or payment to a non-Network provider, we reserve the right to offset Benefits to be
paid to the provider by any amounts that the provider owes us for a maximum of eighteen months. You
will not be held responsible for payment of any offset amounts.
When you assign your Benefits under the Policy to a non-Network provider, and the non-Network provider
submits a claim for payment, you and the non-Network provider represent and warrant the following:

The Covered Health Services were actually provided.

The Covered Health Services were medically appropriate.
In accordance with New Jersey law, a consumer may request a review from the Ombudsman of any
disputed insurance claim settlement where there is reasonable cause to believe than an insurer has failed
or refused to settle a claim in accordance with the provisions of the policy. Consumers seeking a review
must file a complaint with the Ombudsman in any form, which indicates that the complainant is seeking
review of a disputed claim. All complaints must be sent to:
The Office of Insurance Claims Ombudsman
20 West State Street
P.O. Box 472
Trenton, NJ 08625-0472
Telephone: (800)446-7467
Telefax: (609)292-2431
Email: [email protected]
COC.CLM.I.11.NJ
56
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
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 30 days of receiving it.
If you are not satisfied with our decision, you have the right to take your complaint to the Department of
Banking and Insurance.
How to Appeal a Claim Decision
An Adverse Benefit Determination means a denial, reduction, or termination of, or a failure to provide or
make a payment (in whole or in part) for a benefit, including any such denial, reduction, termination, or
failure to provide or make a payment that is based on: a determination of an individual's eligibility to
participate in a plan or health insurance coverage; a determination that a benefit is not a covered benefit;
the imposition of a preexisting condition exclusion, source-of-injury exclusion, network exclusion, or other
limitation on otherwise covered benefits; a determination that a benefit is experimental, investigational, or
not medically necessary or appropriate; or a rescission of coverage.
A Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been
upheld by a plan or issuer at the completion or exhaustion of the internal appeals process.
You have the right to appeal an Adverse Benefit Determination or Final Internal Adverse Benefit
Determination. You may write or call us within 60 days of the decision asking that it be reconsidered. You
may also designate a representative (like your Physician) to appeal on your behalf. You will receive a
written notice of the decision within 5 business days of the date we receive all of the necessary
information to process your appeal. This notice will include the reasons for the determination and, if the
original decision is upheld, the clinical rationale for the decision.
If you are still unsatisfied with our decision, you can ask us in writing to formally reconsider your appeal.
You have the right to request (free of charge) documents relevant to your claim and/or appeal and to
present evidence. You have the right to receive the rationale or new evidence relied upon in connection
with the claim in advance of the date we must provide notice of our decision.
Post-service Claims
Post-service claims are those claims that are filed for payment of Benefits after medical care has been
received.
COC.CPL.I.11.NJ
57
Pre-service Requests for Benefits
Pre-service requests for Benefits are those requests that require prior authorization or benefit
confirmation prior to receiving medical care.
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
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.
Appeals Determinations
Pre-service Requests for Benefits and Post-service Claim Appeals
For procedures associated with urgent requests for Benefits, see Urgent Appeals that Require Immediate
Action below.
You will be provided written or electronic notification of the decision on your appeal as follows:

For appeals of pre-service requests for Benefits as identified above, the first level appeal will be
conducted and you will be notified of the decision within 5 days from receipt of a request for appeal
of a denied request for Benefits. If you are not satisfied with the first level appeal decision, you
have the right to request a second level appeal. Your second level appeal request must be
submitted to us within 60 days from receipt of the first level appeal decision. The second level
appeal will be conducted and you will be notified of the decision within 20 business days from
receipt of a request for review of the first level appeal decision. The second level appeal process
will provide you (or your provider, if applicable) the opportunity to pursue your appeal before a
panel of Physicians and/or other providers that we select who have not been previously involved in
the decision being appealed.
COC.CPL.I.11.NJ
58

For appeals of post-service claims as identified above, the first level appeal will be conducted and
you will be notified of the decision within 5 business days from receipt of a request for appeal of a
denied claim. If you are not satisfied with the first level appeal decision, you have the right to
request a second level appeal. Your second level appeal request must be submitted to us within 60
days from receipt of the first level appeal decision. The second level appeal will be conducted and
you will be notified of the decision within 20 business days from receipt of a request for review of
the first level appeal decision.
Our decision is based on whether or not Benefits are available under the Policy for the proposed
treatment or procedure.
Urgent Appeals that Require Immediate Action
Your appeal may require immediate action if you have a non-life-threatening condition that requires care
by a provider within 24 hours. In these urgent situations:

The appeal does not need to be submitted in writing. You or your Physician should call us as soon
as possible.

We will provide you with a written or electronic determination within 72 hours following receipt of
your request for review of the determination, taking into account the seriousness of your condition.

If we need more information from your Physician to make a decision, we will notify you of the
decision by the end of the next business day following receipt of the required information.
The appeal process for urgent situations does not apply to prescheduled treatments, therapies or
surgeries.
External Review Program
If you are not satisfied with the results of the appeal process, you have the right to appeal the denial
through the Independent Health Care Appeals Program. The written notification of the denial will include
an application for external review with instructions.
You must send the application to the address shown below within 60 days of receipt of the written
notification of the denial.
Department of Banking and Insurance
Consumer Protection Services
Office of Managed Care
PO Box 325
The application fee is $25. If there is financial hardship the reduced fee is $2. The Department of Banking
and Insurance determines financial hardship based on evidence that one or more members of your
household is receiving assistance from the Pharmaceutical Assistance to the Aged and Disabled
program, Medicaid, NJ FamilyCare, General Assistance, SSI, or New Jersey Unemployment Assistance.
We pay for the cost of the external appeal.
The decision of the Independent Health Care Appeals Program will be binding on us.
Rescission of coverage does not qualify for external review.
COC.CPL.I.11.NJ
59
Section 7: Coordination of Benefits
Benefits When You Have Coverage under More than One Plan
This section describes how Benefits under the Policy will be coordinated with those of any other plan that
provides benefits to you.
When Coordination of Benefits Applies
This coordination of benefits (COB) provision applies when a person has health care coverage under
more than one Plan. Plan is defined below. For instance, you may be covered by this Certificate as an
employee and by another Plan as a Dependent of your spouse. If you are covered by more than one
Plan, this provision allows us to coordinate what we pay or provide with what another Plan pays or
provides. This provision sets forth the rules for determining which is the Primary Plan and which is the
Secondary Plan. Coordination of benefits is intended to avoid duplication of benefits while at the same
time preserving certain rights to coverage under all Plans under which you are covered.
Definitions
The words shown below have special meanings when used in this provision. Please read these
definitions carefully. Throughout this provision, these defined terms appear with their initial letter
capitalized.
Allowable Expense - The charge for any health care service, supply or other item of expense for which
you are liable when the health care service, supply or other item of expense is covered at least in part
under any of the Plans involved, except where a statute requires another definition, or as otherwise stated
below.
When this Plan is coordinating benefits with a Plan that provides benefits only for dental care, vision care,
prescription drugs or hearing aids, Allowable Expense is limited to like items of expense.
We will not consider the difference between the cost of a private Hospital room and that of a semi-private
Hospital room as an Allowable Expense unless the stay in a private room is Medically Necessary and
appropriate.
When this Plan is coordinating benefits with a Plan that restricts coordination of benefits to a specific
coverage, we will only consider corresponding services, supplies or items of expense to which
coordination of benefits applies as an Allowable Expense.
Claim Determination Period - A calendar year, or any portion of a calendar year, during which you are
covered by this Plan and at least one other Plan and incur one or more Allowable Expense(s) under such
Plans.
Plan - Coverage with which coordination of benefits is allowed. Plan includes:

Group insurance and group Subscriber contracts, including insurance continued pursuant to a
federal or state continuation law;

Self-funded arrangements of group or group-type coverage, including insurance continued
pursuant to a federal or state continuation law;

Group or group-type coverage through a health maintenance organization (HMO) or other
prepayment, group practice and individual practice plans, including insurance continued pursuant
to a federal or state continuation law;

Group hospital indemnity benefit amounts that exceed $150.00 per day;
COC.COB.I.11.NJ
60

Medicare or other governmental benefits, except when, pursuant to law, the benefits must be
treated as in excess of those of any private insurance Plan or non-governmental Plan.
Plan does not include:

Individual or family insurance contracts or Subscriber contracts;

Individual or family coverage through a health maintenance organization or under any other
prepayment, group practice and individual practice Plans;

Group or group-type coverage where the cost of coverage is paid solely by you except that
coverage being continued pursuant to a federal or state continuation law shall be considered a
Plan;

Group hospital indemnity benefit amounts of $150.00 per day or less;

School accident-type coverage;

A state Plan under Medicaid.
Primary Plan - A Plan whose benefits for your health care coverage must be determined without taking
into consideration the existence of any other Plan. There may be more than one Primary Plan. A Plan will
be the Primary Plan if either of the below exist:

The Plan has no order of benefit determination rules, or it has rules that differ from those contained
in this Coordination of Benefits provision; or

All Plans which cover you use order of benefit determination rules consistent with those contained
in the Coordination of Benefits provision and under those rules, the plan determines its benefits
first.
Reasonable and Customary - An amount that is not more than the usual or customary charge for the
service or supply as determined by us, based on a standard which is most often charged for a given
service by a provider within the same geographic area.
Secondary Plan - A Plan which is not a Primary Plan. If you are covered by more than one Secondary
Plan, the order of benefit determination rules of this Coordination of Benefits provision shall be used to
determine the order in which the benefits payable under the multiple Secondary Plans are paid in relation
to each other. The benefits of each Secondary Plan may take into consideration the benefits of the
Primary Plan or Plans and the benefits of any other Plan which, under this Coordination of Benefits
provision, has its benefits determined before those of that Secondary Plan.
Primary and Secondary Plan
We consider each Plan separately when coordinating payments.
The Primary Plan pays or provides services or supplies first, without taking into consideration the
existence of a Secondary Plan. If a Plan has no coordination of benefits provision, or if the order of
benefit determination rules differ from those set forth in these provisions, it is the Primary Plan.
A Secondary Plan takes into consideration the benefits provided by a Primary Plan when, according to
the rules set forth below, the Plan is the Secondary Plan. If there is more than one Secondary Plan, the
order of benefit determination rules determine the order among the Secondary Plans. During each claim
determination period the Secondary Plan(s) will pay up to the remaining unpaid Allowable Expenses, but
no Secondary Plan will pay more than it would have paid if it had been the Primary Plan. The method the
Secondary Plan uses to determine the amount to pay is set forth below in the "Procedures to be Followed
by the Secondary Plan to Calculate Benefits" section of this provision.
COC.COB.I.11.NJ
61
The Secondary Plan shall not reduce Allowable Expenses for Medically Necessary and appropriate
services or supplies on the basis that precertification, preapproval, notification or second surgical opinion
procedures were not followed.
Order of Benefit Determination Rules
The benefits of the Plan that covers you as an employee, member, Subscriber or retiree shall be
determined before those of the Plan that covers you as a Dependent. The coverage as an employee,
member, Subscriber or retiree is the Primary Plan.
The benefits of the Plan that covers you as an employee who is neither laid off nor retired, or as a
Dependent of such person, shall be determined before those for the Plan that covers you as a laid off or
retired employee, or as such a person's Dependent. If the other Plan does not contain this rule, and as a
result the Plans do not agree on the order of benefit determination, this portion of this provision shall be
ignored.
The benefits of the Plan that covers you as an employee, member, Subscriber or retiree, or Dependent of
such person, shall be determined before those of the Plan that covers you under a right of continuation
pursuant to federal or state law. If the other Plan does not contain this rule, and as a result the Plans do
not agree on the order of benefit determination, this portion of this provision shall be ignored.
If a child is covered as a Dependent under Plans through both parents, and the parents are neither
separated nor divorced, the following rules apply:

The benefits of the Plan of the parent whose birthday falls earlier in the Calendar year shall be
determined before those of the parent whose birthday falls later in the Calendar year.

If both parents have the same birthday, the benefits of the Plan which covered the parent for a
longer period of time shall be determined before those of the Plan which covered the other parent
for a shorter period of time.

"Birthday," as used above, refers only to month and day in a calendar year, not the year in which
the parent was born.

If the other Plan contains a provision that determines the order of benefits based on the gender of
the parent, the birthday rule in this provision shall be ignored.
If a child is covered as a Dependent under Plans through both parents, and the parents are separated or
divorced, the following rules apply:

The benefits of the Plan of the parent with custody of the child shall be determined first.

The benefits of the Plan of the spouse of the parent with custody shall be determined second.

The benefits of the Plan of the parent without custody shall be determined last.

If the terms of a court decree state that one of the parents is responsible for the health care
expenses for the child, and if the entity providing coverage under that Plan has actual knowledge of
the terms of the court decree, then the benefits of that Plan shall be determined first. The benefits
of the Plan of the other parent shall be considered as secondary. Until the entity providing
coverage under the Plan has knowledge of the terms of the court decree regarding health care
expenses, this portion of this provision shall be ignored.
If the above order of benefits does not establish which Plan is the Primary Plan, the benefits of the Plan
that covers the employee, member or Subscriber for a longer period of time shall be determined before
the benefits of the Plan(s) that covered the person for a shorter period of time.
COC.COB.I.11.NJ
62
Effect on the Benefits of This Plan
In order to determine which procedure to follow it is necessary to consider:

The basis on which the Primary Plan and the Secondary Plan pay benefits; and

Whether the provider who provides or arranges the services and supplies is in the Network of
either the Primary Plan or the Secondary Plan.
Benefits may be based on the Reasonable and Customary Charge (R&C), or some similar term. This
means that the provider bills a charge and you may be held liable for the full amount of the billed charge.
In this section, a Plan that bases benefits on a reasonable and customary charge is called an "R&C Plan."
Benefits may be based on a contractual fee schedule, sometimes called a negotiated fee schedule, or
some similar term. This means that although a provider, called a Network provider, bills a charge, you
may be held liable only for an amount up to the negotiated fee. In this section, a Plan that bases benefits
on a negotiated fee schedule is called a "Fee Schedule Plan." If you use the services of a non-Network
provider, the Plan will be treated as an R&C Plan even though the Plan under which you are covered
allows for a fee schedule.
Payment to the provider may be based on a "capitation". This means that the HMO or other Plan pays the
provider a fixed amount per Covered Person. You are liable only for the applicable deductible,
Coinsurance or Copayment. If you use the services of a non-Network provider, the HMO or other Plan will
only pay benefits in the event of emergency care or urgent care. In this section, a Plan that pays
providers based upon capitation is called a "Capitation Plan."
In the rules below, "provider" refers to the provider who provides or arranges the services or supplies and
"HMO" refers to a health maintenance organization plan.
Primary Plan is R&C Plan and Secondary Plan is R&C Plan
The Secondary Plan shall pay the lesser of:

The difference between the amount of the billed charges and the amount paid by the Primary Plan;
or

The amount the Secondary Plan would have paid if it had been the Primary Plan.
When the benefits of the Secondary Plan are reduced as a result of this calculation, each benefit shall be
reduced in proportion, and the amount paid shall be charged against any applicable benefit limit of the
Plan.
Primary Plan is Fee Schedule Plan and Secondary Plan and Secondary Plan is Fee Schedule Plan
If the provider is a Network provider in both the Primary Plan and the Secondary Plan, the Allowable
Expense shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of:

The amount of any deductible, Coinsurance or Copayment required by the Primary Plan; or

The total amount the provider receives from the Primary Plan, the Secondary Plan and you shall not
exceed the fee schedule of the Primary Plan. In no event shall you be responsible for any payment in
excess of the Copayment, Coinsurance or deductible of the Secondary Plan.
Primary Plan is R&C Plan and Secondary Plan is Fee Schedule Plan
If the provider is a Network provider in the Secondary Plan, the Secondary Plan shall pay the lesser of:

The difference between the amount of the billed charges for the Allowable Expenses and the
amount paid by the Primary Plan; or
COC.COB.I.11.NJ
63

You shall only be liable for the Copayment, deductible or Coinsurance under the Secondary Plan if you
have no liability for Copayment, deductible or Coinsurance under the Primary Plan and the total payments
by both the Primary and Secondary Plans are less than the provider's billed charges. In no event shall
you be responsible for any payment in excess of the Copayment, Coinsurance or deductible of the
Secondary Plan.
Primary Plan is Fee Schedule Plan and Secondary Plan is R&C Plan
If the provider is a Network provider in the Primary Plan, the Allowable Expense considered by the
Secondary Plan shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser
of:


Primary Plan is Fee Schedule Plan and Secondary Plan is R&C Plan or Fee Schedule Plan
If the Primary Plan is an HMO plan that does not allow for the use of non-Network providers except in the
event of urgent care or emergency care and the service or supply you receive from a non-Network
provider is not considered as urgent care or emergency care, the Secondary Plan shall pay benefits as if
it were the Primary Plan.
Primary Plan is Capitation Plan and Secondary Plan is Fee Schedule Plan or R&C Plan
If you receive services or supplies from a provider who is in the Network of both the Primary Plan and the
Secondary Plan, the Secondary Plan shall pay the lesser of:


Primary Plan is Capitation Plan or Fee Schedule Plan or R&C Plan and Secondary Plan is
Capitation Plan
If you receive services or supplies from a provider who is in the Network of the Secondary Plan, the
Secondary Plan shall be liable to pay the capitation to the provider and shall not be liable to pay the
deductible, Coinsurance or Copayment imposed by the Primary Plan. You shall not be liable to pay any
deductible, Coinsurance or Copayments of either the Primary Plan or the Secondary Plan.
Primary Plan is an HMO and Secondary Plan is an HMO
provider is not considered as urgent care or emergency care, but the provider is in the Network of the
Secondary Plan, the Secondary Plan shall pay benefits as if it were the Primary Plan, except that the
Primary Plan shall pay out-of-Network services, if any, authorized by the Primary Plan.
COC.COB.I.11.NJ
64
Section 8: 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 Enrolling Group's Benefit plan and how it may affect you.
We help finance or administer the Enrolling Group's Benefit plan in which you are enrolled. We do not
provide medical services or make treatment decisions. This means:

We communicate to you decisions about whether the Enrolling Group's Benefit plan 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 Certificate.

The plan may not pay for all treatments you or your Physician may believe are necessary. If the
plan 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 and Enrolling Groups
The relationships between us and Network providers and Enrolling Groups are solely contractual
relationships between independent contractors. Network providers and Enrolling Groups are not our
agents or employees. Neither we nor any of our employees are agents or employees of Network
providers or the Enrolling Groups.
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 unless:

It is determined by a court of law under the provisions of the New Jersey Health Care Carrier
Accountability Act, 2001 that the provider acted as our agent and that we had the right to exercise
influence or control, or actually exercised influence or control over the health care treatment
decisions of that provider.

The other elements for establishing our liability under the Act are proven.
We are not considered to be an employer for any purpose with respect to the administration or provision
of benefits under the Enrolling Group's Benefit plan. We are not responsible for fulfilling any duties or
obligations of an employer with respect to the Enrolling Group's Benefit plan.
The Enrolling Group is solely responsible for all of the following:

Enrollment and classification changes (including classification changes resulting in your enrollment
or the termination of your coverage).

The timely payment of the Policy Charge to us.

Notifying you of the termination of the Policy.
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65
When the Enrolling Group purchases the Policy to provide coverage under a benefit plan governed by the
Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. §1001 et seq., we are not the plan
administrator or named fiduciary of the benefit plan, as those terms are used in ERISA. If you have
questions about your welfare benefit plan, you should contact the Enrolling Group. If you have any
questions about this statement or about your rights under ERISA, contact the nearest area office of the
Employee Benefits Security Administration, U. S. Department of Labor.
Your Relationship with Providers and Enrolling Groups
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.
The relationship between you and the Enrolling Group is that of employer and employee, Dependent or
other classification as defined in the Policy.
Notice
When we provide written notice regarding administration of the Policy to an authorized representative of
the Enrolling Group, that notice is deemed notice to all affected Subscribers and their Enrolled
Dependents. The Enrolling Group is responsible for giving notice to you.
Statements by Enrolling Group or Subscriber
All statements made by the Enrolling Group or by a Subscriber shall be deemed representations and not
warranties. Except for fraudulent statements, we will not use any statement made by the Enrolling Group
to void the Policy unless it is contained in a written application signed by the Enrolling Group. No such
statement shall void or reduce coverage under the Policy or be used in defense of a legal action unless it
is contained in a written application signed by the group or a Subscriber, as applicable.
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.
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
COC.LGL.I.11.NJ
66
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, they do not alter or affect your Benefits and are subject to change
without notice. 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
Subject to your appeal rights set forth in the Questions, Complaints and Appeals Procedures Section, we

Make initial interpretations of Benefits under the Policy.

Make initial interpretations of the other terms, conditions, limitations and exclusions set out in the
Policy, including this Certificate, the Schedule of Benefits and any Riders and/or Amendments.

Make factual determinations related to the Policy and its Benefits.
We may delegate this authority to other persons or entities that provide services in regard to the
administration of the Policy.
This discretionary authority to interpret Benefits, other terms, conditions, limitations and exclusions under
the Policy is subject to modification or reversal by a court or regulatory agency with appropriate
jurisdiction.
It does not alter or affect your rights under state or federal statutes or regulations, including the right to
bring legal action against us. It does not alter or affect your rights to make a complaint or appeal a denial,
including use of the Independent Health Care Appeals Program.
In certain circumstances, for purposes of overall cost savings or efficiency, we may, in our discretion, 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.
Administrative Services
We may, in our sole discretion, arrange for various persons or entities to provide administrative services
in regard to the Policy, such as claims processing. The identity of the service providers and the nature of
COC.LGL.I.11.NJ
67
the services they provide may be changed from time to time in our sole discretion. 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.
Amendments to the Policy
Any provision of the Policy which, on its effective date, is in conflict with the requirements of state or
federal statutes or regulations (of the jurisdiction in which the Policy is delivered) is hereby amended to
conform to the minimum requirements of such statutes and regulations.
No other change may be made to the Policy unless it is made by an Amendment or Rider which has been
signed by one of our officers and the Enrolling Group. All of the following conditions apply:

Amendments to the Policy are effective 31 days after we send written notice to the Enrolling Group.

Riders are effective on the date we specify.

No agent has the authority to change the Policy or to waive any of its provisions.

No one has authority to make any oral changes or amendments to the Policy.
Any subsequent changes in Benefits will be shown in a Rider or Amendment issued to Subscribers.
Information and Records
We may use your individually identifiable health information to administer the 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 the 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 Subscriber'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 the 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 the Policy, we and our
related entities may use and transfer the information gathered under the 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.
COC.LGL.I.11.NJ
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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 the Policy do not substitute for and do not affect any requirements for coverage
by workers' compensation insurance.
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 the Policy.

All or some of the payment was made in error.
Except in cases of fraudulent claims, we will make a written request for the reimbursement no later than
18 months after the date the first payment of the claim was made. The refund equals the amount we paid
in excess of the amount we should have paid under the Policy. If the refund is due from another person or
organization, the Covered Person agrees to help us get the refund when requested.
In seeking reimbursement for the overpayment from the health care provider, we will not collect or attempt
to collect:

the funds for the reimbursement on or before the 45th calendar day following the submission of the
reimbursement request to the health care provider;

the funds for the reimbursement if the health care provider disputes the request and initiates an
appeal on or before the 45th calendar day following the submission of the reimbursement request
to the health care provider and until the health care provider's rights to appeal are exhausted; or

a monetary penalty against the reimbursement request, including but not limited to, an interest
charge or a late fee.
We may collect the funds for the reimbursement request by assessing them against payment of any
future claims submitted by the health care provider after the 45th calendar day following the submission
of the reimbursement request to the health care provider or after the health care provider's rights to
appeal have been exhausted if we submit an explanation in writing to the provider in sufficient detail so
that the provider can reconcile each Covered Person's bill.
If we determine that the overpayment to the health care provider is a result of fraud committed by the
health care provider and we have conducted its investigation and reported the fraud to the Office of the
Insurance Fraud Prosecutor as required by law, we may collect an overpayment by assessing it against
payment of any future claim submitted by the health care provider.
Limitation of Action
No legal action may be brought against us prior to the expiration of 60 days after proof of loss has been
filed. Additionally, 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.
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Entire Policy
The Policy issued to the Enrolling Group, including this Certificate, the Schedule of Benefits, the Enrolling
Group's application and any Riders and/or Amendments, constitutes the entire Policy.
COC.LGL.I.11.NJ
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Section 9: 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.
An Alternate Facility may also provide Mental Health Services, Neurobiological Disorder - Autism
Spectrum Disorder Services or Substance Use Disorder Services on an outpatient or inpatient basis.
Amendment - any attached written description of additional or alternative provisions to the Policy.
Amendments are effective only when signed by us and the Enrolling Group. Amendments are subject to
all conditions, limitations and exclusions of the Policy, except for those that are specifically amended.
Annual Deductible - for Benefit plans that have an 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. Refer to the Schedule of
Benefits to determine whether or not your Benefit plan is subject to payment of an Annual Deductible and
for details about how the Annual Deductible applies.
Autism Spectrum Disorders - a group of neurobiological disorders that includes Autistic Disorder,
Rhett's Syndrome, Asperger's Disorder, Childhood Disintegrated Disorder and Pervasive Development
Disorders Not Otherwise Specified (PDDNOS).
Behavioral Interventions Based on ABA - interventions or strategies based upon learning theory that
are intended to improve socially important behavior of an individual using instructional and environmental
modifications that have been evaluated through scientific research using reliable and objective
measurements, including the empirical identification of functional relations between behavior and
environmental factors. Behavior intervention strategies based on ABA include, but are not limited to:

chaining;

functional analysis;

functional assessment;

functional communication training;

modeling, including video modeling (also known as imitation training);

procedures designed to reduce challenging and dangerous behaviors (e.g. differential
reinforcement, extinction, time out, and response cost);

prompting; and

reinforcement systems, including differential reinforcement, shaping and strategies to promote
generalization.
Benefits - your right to payment for Covered Health Services that are available under the Policy. Your
right to Benefits is subject to the terms, conditions, limitations and exclusions of the Policy, including this
Certificate, the Schedule of Benefits and any attached Riders and/or Amendments.
Biologically-Based Mental Illness - a mental or nervous condition that is caused by a biological disorder
of the brain and results in a clinically significant or psychological syndrome or pattern that substantially
COC.DEF.I.11.NJ
71
limits the functioning of the person with the illness, including but not limited to, schizophrenia,
schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic
disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder or
autism.
Civil Union Partners - an individual who is a partner in a civil union. A "civil union" is defined as, the
legally recognized union of two eligible individuals, of the same sex, established pursuant to (or otherwise
compliant with) New Jersey law. A civil union also includes relationships entered into under the laws of
other jurisdictions provided such relationships provide substantially all of the rights and benefits of
marriage.
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 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:

Medically Necessary or medically appropriate.


Covered Person - either the Subscriber or an Enrolled Dependent, but this term applies only while the
person is enrolled under the Policy. References to "you" and "your" throughout this Certificate 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 Subscriber's legal spouse, Civil Union Partner or a child of the Subscriber or the
Subscriber's spouse or Civil Union Partner. All references to the spouse of a Subscriber shall include a
Domestic Partner or Life Partner. The term child includes any of the following:

A natural child.
COC.DEF.I.11.NJ
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
A stepchild.

A legally adopted child.

A child placed for adoption.

A child for whom legal guardianship has been awarded to the Subscriber or the Subscriber's
spouse.
To be eligible for coverage under the Policy, a Dependent must reside within the United States.
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 an unmarried dependent child age 26 or older who is or becomes disabled
and dependent upon the Subscriber.
If we are not notified that a child no longer meets the above requirements, the Subscriber must reimburse
us for any Benefits that we pay for a child at a time when the child did not satisfy these conditions.
A Dependent also includes a child for whom health care coverage is required through a Qualified Medical
Child Support Order or other court or administrative order. The Enrolling Group is responsible for
determining if an order meets the criteria of a Qualified Medical Child Support Order.
A Dependent does not include anyone who is also enrolled as a Subscriber. No one can be a Dependent
of more than one Subscriber.
When Coverage Ends.
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 your geographic area. The fact that a
Hospital is a Network Hospital does not mean that it is a Designated Facility.
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 your geographic area.
The fact that a Physician is a Network Physician does not mean that he or she is a Designated Physician.
Developmental Disability - a severe, chronic disability of a person which:

is attributable to a mental or physical impairment or combination of mental or physical impairments;

is manifested before age 22;

is likely to continue indefinitely;

results in substantial functional limitations in three or more of the following areas of major life
activity, that is, self-care, receptive and expressive language, learning, mobility, self-direction and
capacity for independent living or economic self-sufficiency; and

reflects the need for a combination and sequence of special inter-disciplinary or generic care,
treatment or other services which are of lifelong or extended duration and are individually planned
and coordinated. Developmental disability includes but is not limited to severe disabilities
attributable to mental retardation, autism, cerebral palsy, epilepsy, spina-bifida and other
neurological impairments where the above criteria are met.
Domestic Partner - a person of the opposite or same sex with whom the Subscriber has established a
Domestic Partnership under either statutory or common law.
COC.DEF.I.11.NJ
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Domestic Partnership - a relationship between a Subscriber and one other person of the opposite or
same sex. All of the following requirements apply to both persons:

They must not be related by blood or a degree of closeness that would prohibit marriage in the law
of the state in which they reside.

They must not be currently married to, or a Domestic Partner of, another person under either
statutory or common law.

They must share the same permanent residence and the common necessities of life.

They must be financially interdependent.
As of February 19, 2007, only those persons age 62 or older may enter into a Domestic Partnership in the
State of New Jersey. Domestic Partnerships registered prior to February 19, 2007 may continue to
renew/purchase coverage.
Same sex Domestic Partners who entered into a Domestic Partnership prior to February 19, 2007 have
the right to enter into a Civil Union pursuant to New Jersey Law. Entry into a Civil Union will terminate the
Domestic Partnership.
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.

Is not implantable within the body.
Eligible Expenses - for Covered Health Services, incurred while the 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 in accordance with our reimbursement policy guidelines. We develop
our reimbursement policy guidelines following evaluation and validation of all provider billings in
accordance with one or more of the following methodologies:

(CMS).



source or determination that we accept.
For Network Providers, Eligible Expenses are based upon the contracted rate between us and the
Network provider. For non-Network providers, Eligible Expenses are based upon either the Prevailing
Health Care System (PHCS) fees or the Maximum Non-Network Reimbursement Program (MNRP),
depending upon what the Enrolling Group has purchased. The provision that applies to your plan (PHCS
or MNRP) is outlined in your Schedule of Benefits under the heading Eligible Expenses.
COC.DEF.I.11.NJ
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because the amount paid for Eligible Expenses may be a lesser amount
Eligible Person - an employee of the Enrolling Group or other person whose connection with the
Enrolling Group meets the eligibility requirements specified in both the application and the Policy. An
Eligible Person must reside within the United States.
Emergency - a medical condition manifesting itself by acute symptoms of sufficient severity including, but
not limited to severe pain, psychiatric disturbances and/or symptoms of substance abuse such that a
prudent lay person, who possesses an average knowledge of health and medicine, could reasonably
expect the absence of immediate attention to result in:

placing the health of the individual (or with respect to a pregnant woman, the health of the woman
or her unborn child) in serious jeopardy; or

serious impairment to bodily functions; or

serious dysfunction of a bodily organ or part.
With respect to a pregnant woman who is having contractions, an Emergency exists where there is
inadequate time to effect a safe transfer to another Hospital before delivery or if the transfer may pose a
threat to the health or safety of the woman or the unborn child.
Emergency Health Services - health care services and supplies, including a medical screening exam,
necessary for the evaluation and treatment of an Emergency.
Health services are considered to be for the treatment of an Emergency as long as transfer of the
Covered Person to a Network provider is precluded because of risk to the Covered Person's health or
because transfer would be unreasonable, given the distance involved in the transfer or the nature of the
medical condition.
Enrolled Dependent - a Dependent who is properly enrolled under the Policy.
Enrolling Group - the employer, or other defined or otherwise legally established group, to whom the
Policy is issued.
Experimental or Investigational Service(s) - medical, surgical, diagnostic, psychiatric, mental health,
substance use disorders or other health care services, technologies, supplies, treatments, procedures,
drug therapies, medications or devices that, at the time we make a determination regarding coverage in a
particular case, are determined to be any of the following:

Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the
proposed use and not identified in the American Hospital Formulary Service or the United States
Pharmacopoeia Dispensing Information as appropriate for the proposed use; except that coverage
is provided for a drug which has been prescribed for a treatment for which the drug has not been
approved by the FDA provided the drug is recognized for the specific treatment for which the drug
has been prescribed in one of the following 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 Pharmacists' American Hospital Formulary Service Drug Information (AHES-DI) or, it is
recommended by a clinical study or review article in a major peer reviewed professional journal.
However, there is no coverage for any drug which the FDA has determined to be contraindicated
for the specific treatment for which the drug has been prescribed.
COC.DEF.I.11.NJ
75

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 1, 2 or 3 clinical trial set
forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight.
Exceptions:

Clinical trials for which Benefits are available as described under Clinical Trials in Section 1:

Life -Threatening Sickness or Condition. If you have a life-threatening Sickness or condition (one
that is likely to cause death within one year of the request for treatment) we may, in our discretion,
consider an otherwise 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.
Family Cost Share - The New Jersey Early Intervention System (NJEIS) family cost share is a
progressive co-payment per hour of direct services provided in accordance with an Individualized Family
Service Plan (IFSP) that is based upon family size and NJEIS determined income along the federal
poverty level guidelines.
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 - a program or organization authorized by law to provide health care services in
the home or is Medicare certified.
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.
Individualized Family Service Plan (IFSP) - The IFSP is both a plan and a process. The plan is a
written document that identifies the outcomes, services and supports needed for the child and family. The
process is ongoing assessment to gather, share, and exchange information between the family and the
early intervention practitioners to help parents make informed choices about early intervention services
and other needed services for the child and family.
Infertility - the disease or condition that results in the abnormal function of the reproductive system such
that a person is not able to do one of the following:

Impregnate another person.

Conceive after one year of unprotected intercourse if the female partner is under 35 years of age.

Conceive after six months of unprotected intercourse if the female partner is 35 years of age or
older or one of the partners is considered medically sterile.

Carry a pregnancy to live birth.
Inherited Metabolic Disease - a disease caused by an inherited abnormality of body chemistry.
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Initial Enrollment Period - the initial period of time during which Eligible Persons may enroll themselves
and their Dependents under the Policy.
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.
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 use disorder
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.
Low Protein Modified Food Product - a food product that is specifically formulated to have less than
one gram of protein per serving and is intended to be used under the direction of a Physician for the
dietary treatment of an Inherited Metabolic Disease, but does not include a natural food that is naturally
low in protein.
Manipulative Treatment - the therapeutic application of chiropractic and/or osteopathic manipulative
treatment with or without ancillary physiologic treatment and/or rehabilitative methods rendered to
restore/improve motion, reduce pain and improve function in the management of an identifiable
neuromusculoskeletal condition.
Medical Food - a food that is intended for the dietary treatment of a disease or condition for which
nutritional requirements are established by medical evaluation and is formulated to be consumed or
administered enterally under the direction of a Physician.
Medically Necessary - health care services provided for the purpose of preventing, evaluating,
diagnosing or treating a Sickness, Injury, Mental Illness, substance use disorder, condition, disease or its
symptoms, that are all of the following as determined by us or our designee, within our sole discretion.

In accordance with Generally Accepted Standards of Medical Practice.

Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered
effective for your Sickness, Injury, Mental Illness, substance use disorder, disease or its symptoms.

Not mainly for your convenience or that of your doctor or other health care provider.

Not more costly than an 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.
COC.DEF.I.11.NJ
77
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. The decision to
apply Physician specialty society recommendations, the choice of expert and the determination of when
to use any such expert opinion, shall be within our sole discretion.
With respect to Pharmaceutical Products, no prescribed drug shall be excluded on the basis that the drug
has not been approved by the United States Food and Drug Administration (USFDA) for the use for which
the drug has been prescribed, if such drug is recognized as medically appropriate for the specific
treatment for which it has been prescribed by the American Hospital Formulary Service Drug Information,
the United States Pharmacopoeia Drug Information or a clinical study or review article in a major peer
reviewed professional journal.
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 Use Disorder Designee - the organization or individual, designated by us,
that provides or arranges Mental Health Services, Neurobiological Disorder - Autism Spectrum Disorder
Services and Substance Use Disorder Services for which Benefits are available under the Policy.
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 the Policy. Mental Illness includes Biologically Based Mental Illnesses.
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 by way of their participation in the Shared Savings Program. 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 - for Benefit plans that have a Network Benefit level, this is the description of how
Benefits are paid for Covered Health Services provided by Network providers. Refer to the Schedule of
Benefits to determine whether or not your Benefit plan offers Network Benefits and for details about how
Network Benefits apply.
New Jersey Early Intervention System (NJEIS) - The New Jersey Early Intervention System (NJEIS),
under the Division of Family Health Services, implements New Jersey's statewide system of services for
infants and toddlers, birth to age three, with developmental delays or disabilities, and their families. The
Department of Health and Senior Services is appointed by the Governor as the state lead agency for the
NJEIS.
COC.DEF.I.11.NJ
78
Non-Network Benefits - for Benefit plans that have a Non-Network Benefit level, this is the description of
how Benefits are paid for Covered Health Services provided by non-Network providers. Refer to the
Schedule of Benefits to determine whether or not your Benefit plan offers Non-Network Benefits and for
details about how Non-Network Benefits apply.
Open Enrollment Period - a period of time that follows the Initial Enrollment Period during which Eligible
Persons may enroll themselves and Dependents under the Policy. The Enrolling Group determines the
period of time that is the Open Enrollment Period.
Out-of-Pocket Maximum - for Benefit plans that have an Out-of-Pocket Maximum, this is the maximum
amount you pay every year. Annual Deductibles, Copayments and Coinsurance will apply to the Out-ofPocket Maximum. Refer to the Schedule of Benefits to determine whether or not your Benefit plan is
subject to an Out-of-Pocket Maximum.
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
the Policy.
Pharmaceutical Product 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 which tier a particular Pharmaceutical Product has been assigned through the Internet at
Pharmaceutical Product List Management Committee - the committee that we designate for, among
other responsibilities, classifying Pharmaceutical Products into specific tiers.
Physician - any Doctor of Medicine or Doctor of Osteopathy who is properly licensed and qualified by
law.
Please Note: Any audiologist, podiatrist, dentist, psychologist, chiropractor, chiropodist, optometrist, nurse
midwife, physical therapist, psychologist, registered professional nurse, speech-language pathologist 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 the Policy.
Policy - the entire agreement issued to the Enrolling Group that includes all of the following:

The Group Policy.

This Certificate.



Riders.

Amendments.
These documents make up the entire agreement that is issued to the Enrolling Group.
Policy Charge - the sum of the Premiums for all Subscribers and Enrolled Dependents enrolled under
the Policy.
Pregnancy - includes all of the following:
COC.DEF.I.11.NJ
79

Prenatal care.

Postnatal care.

Childbirth.

Any complications associated with Pregnancy.
Premium - the periodic fee required for each Subscriber and each Enrolled Dependent, in accordance
with the terms of the Policy.
Primary Physician - a Physician who has a majority of his or her practice in general pediatrics, internal
medicine, obstetrics/gynecology, 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.
Related Structured Behavioral Programs - services delivered by a qualified practitioner that are
comprised of multiple intervention strategies (that is, behavioral intervention packages) based upon the
principles of ABA. These packages may include but are not limited to:

activity schedules;

discrete trial instruction;

incidental teaching;

natural environment training;

picture exchange communication system;

pivotal response treatment;

script and script-fading procedures; and

self-management.
Rescission - a retroactive cancellation or discontinuance of coverage, e.g., policy void from enrollment,
or benefits previously paid that are declared void, due to fraud or intentional misrepresentation of material
fact.
Residential Treatment Facility - a facility which provides a program of effective Mental Health Services
or Substance Use Disorder 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 Use Disorder Designee.
COC.DEF.I.11.NJ
80

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
Certificate. Covered Health Services provided by a Rider may be subject to payment of additional
Premiums. Riders are effective only when signed by us and the Enrolling Group and are subject to all
conditions, limitations and exclusions of the Policy except for those that are specifically amended in the
Rider.
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 Standards of Medical
Practice, or when a Semi-private Room is not available.
Shared Savings Program - the Shared Savings Program provides access to discounts from the
provider's charges when services are rendered by those non-Network providers that participate in that
program. We will use the Shared Savings Program to pay claims when doing so will lower the amount you
are responsible to pay for the service. We do not credential the Shared Savings Program providers and
the Shared Savings Program providers are not Network providers. Accordingly, Benefits for Covered
Health Services provided by Shared Savings Program providers will be paid at the Non-Network Benefit
level (except in cases of Emergency Health Services or Network exceptions). When we use the Shared
Savings Program to pay a claim, your responsibility is limited to Coinsurance calculated on the
contractually negotiated discount rate paid to the provider, in addition to any required deductible. You will
not be balance billed for amounts that exceed this contractually negotiated discount rate.
To determine whether a provider is part of the Shared Savings Program you can call the Customer
Service number on your ID card or logon to www.myuhc.com.
Sickness - physical illness, disease or Pregnancy. The term Sickness as used in this Certificate does not
include Mental Illness or substance use disorders, regardless of the cause or origin of the Mental Illness
or substance use disorder.
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, obstetrics/gynecology, family practice or general medicine. For Mental
Health Services and Substance Use Disorder Services, any licensed clinician is considered on the same
basis as a Specialist Physician.
Subscriber - an Eligible Person who is properly enrolled under the Policy. The Subscriber is the person
(who is not a Dependent) on whose behalf the Policy is issued to the Enrolling Group.
Substance Use Disorder Services - Covered Health Services for the diagnosis and treatment of
alcoholism and substance use 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.
COC.DEF.I.11.NJ
81
Total Disability or Totally Disabled - a Subscriber's inability to perform all of the substantial and
material duties of his or her regular employment or occupation; and a Dependent's inability to perform the
normal activities of a person of like age and sex.
Transitional Care - Mental Health Services and Substance Use Disorder 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.

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.
These include:

Well-conducted randomized controlled trials. (Two or more treatments are compared to each other,
and the patient is not allowed to choose which treatment is received.)

Well-conducted cohort studies from more than one institution. (Patients who receive study
treatment are compared to a group of patients who receive standard therapy. The comparison
group must be nearly identical to the study treatment group.)
We have a process by which we compile and review clinical evidence with respect to certain health
services. From time to time, we issue medical and drug policies that describe the clinical evidence
available with respect to specific health care services. These medical and drug policies are subject to
change without prior notice. You can view these policies at www.myuhc.com.
Please note:

If you have a life-threatening Sickness or condition (one that is likely to cause death within one year
of the request for treatment) we may, in our discretion, consider an otherwise Unproven Service to
be a Covered Health Service for that Sickness or condition. Prior to such a consideration, we must
first establish that there is sufficient evidence to conclude that, albeit unproven, the service has
significant potential as an effective treatment for that Sickness or condition.

With respect to Pharmaceutical Products, no prescribed drug shall be excluded on the basis that
the drug has not been approved by the United States Food and Drug Administration (USFDA) for
the use for which the drug has been prescribed, if such drug is recognized as medically appropriate
for the specific treatment for which it has been prescribed by the American Hospital Formulary
Service Drug Information, the United States Pharmacopoeia Drug Information or a clinical study or
review article in a major peer reviewed professional journal.
Urgent Care Center - a facility that provides Covered Health Services that are non-life-threatening but
that require care by a provider within 24 hours.
COC.DEF.I.11.NJ
82
As described in this Amendment, the Certificate is modified to provide coverage for oral
chemotherapeutic agents used to kill or slow the growth of cancerous cells.
Because this Amendment is part of a legal document (the group Policy), 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 the Certificate of Coverage (Certificate) in Section 9: Defined Terms.
1.
The exclusion for outpatient prescription drugs in the Certificate under Section 2: Exclusions and
Limitations, Drugs is replaced with the following:
D. Drugs
1.
Prescription drug products for outpatient use that are filled by a prescription order or refill, except
for oral chemotherapeutic agents used to kill or slow the growth of cancerous cells if this Policy
does not include an Outpatient Prescription Drug Rider. This exclusion also does not apply to oral
agents for controlling blood sugar or to medications used to treat infertility for which Benefits are
provided as described under Diabetes Services and Infertility Services in Section 1: Covered
Health Services.
2.
Self-injectable medications, except as described under Diabetes Services in Section 1: Covered
Health Services. 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.
3.
4.
Services.
5.
6.
7.
UNITEDHEALTHCARE INSURANCE COMPANY
Jeffrey Alter, President
ORALCHEMO.AMD.I.11.NJ
1
Health Resources and Services Administration
(HRSA) Amendment
As described in this Amendment, the Certificate is modified as stated below.
Benefits for Breast Pumps
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. These Benefits are
provided as described under Preventive Care Services in the Certificate, Section 1: Covered Health
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.
As a result of this requirement, the exclusion for supplies, equipment and similar incidental services and
supplies for personal comfort in Section 2: Exclusions and Limitations under Personal Care, Comfort or
Convenience is replaced with the following:
Personal Care, Comfort or Convenience
Supplies, equipment and similar incidental services and supplies for personal comfort. Examples include:



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.


Exercise equipment.


Hot tubs.

Humidifiers.

Jacuzzis.
AMD.HRSA.I.11.NJ
1

Mattresses.


Motorized beds.

Music devices.

Personal computers.

Pillows.


Radios.

Saunas.


Strollers.

Safety equipment.

Treadmills.


Video players.

Whirlpools.
AMD.HRSA.I.11.NJ
2
Outpatient Prescription Drug
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.
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
Benefits for Prescription Drug Products are subject to supply limits that are stated in the Schedule of
Benefits. For a single copayment or coinsurance, the Insured may receive a Prescription Drug Product up
to the stated supply limit. We will cover up to a consecutive 90-day supply of a Prescription Drug Product,
as written by the Physician, subject to the drug manufacturer’s packaging size, or based on supply limits.
When a Prescription Drug Product is packaged or designed to deliver in a manner that provides more
than a consecutive 31-day supply, the copayment or coinsurance that applies will reflect the number of
days dispensed.
Note: Some products are subject to additional supply limits other than day limits based on criteria that the
Company has developed, subject to its 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.
You may determine whether a Prescription Drug Product has been assigned a maximum quantity level for
dispensing through the Internet at www.myuhc.com or by calling Customer Service at the telephone
number on your ID card.
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.
RDR.RXSBN.PLS.I.11.NJ
1
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.
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.
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 Prescription Drug Products from a Network Pharmacy) or the
Allowable Expense (for Prescription Drug Products from a non-Network Pharmacy), less the required
Copayment or Coinsurance, and any deductible that applies.
Benefits may not be available for the Prescription Drug Product after we review the documentation
provided and we determine that the Prescription Drug Product is not a Covered Health Service or it is an
Experimental or Investigational or Unproven Service.
We may also require prior authorization for certain programs which may have specific requirements for
participation and/or activation of an enhanced level of Benefits associated with such programs. You may
access information on available programs and any applicable prior authorization, participation or
activation requirements associated with such programs through the Internet at www.myuhc.com or by
Approval Process for Prescription Drug Products that the Covered
Person wants considered at a Lower Tier copayment
The prescribing Physician must request our prior approval for a lower tier copayment for a higher tier drug
by contacting the Customer Care Department and providing all relevant information. We will respond to
the Physician by telephone within one business day after the receipt of all requested documentation from
the Physician. If we fail to respond within that time period, the request is deemed approved. The request
for approval must be based on the Physician's certification that the Prescription Drug Product is medically
necessary as defined below and the current drugs available in the lower Tiers are not effective for the
Covered Person.
A Prescription Drug Product which is not on the Prescription Drug List will be considered medically
necessary if:

It is approved by the U.S. Federal Food and Drug Administration ("FDA") or its use is supported by
one or more citations included or approved for inclusion in The American Hospital Formulary Drug
Information or the United States Pharmacopeia- Drug Information, or it is recommended by a
clinical study or review article in a major peer reviewed professional journal; and
2

The prescribing Physician states that all Prescription Drug Products on the Prescription Drug List
used to treat each disease state has been ineffective in the treatment of your disease or condition,
or all such drugs have caused or are reasonably expected to cause you adverse or harmful
reactions.
If the request is denied by telephone, we will also provide you and the Physician a written denial within 5
business days of the request. The written denial will include the clinical reason for the denial.
If you are dissatisfied with our decision, you should follow the procedures described in the Certificate for
questions, complaints and appeals. If you want to contest our decision you may apply to the Independent
Health Care Appeals Program for a review. You must make your application within 60 days of the date
you were notified of the decision. Your notification of our decision will include specific instructions as to
how you or your provider may arrange for an external appeal and will also include any forms required to
initiate the appeal.
Emergency
Prescription Drug Products dispensed at a Non-Network Pharmacy for an Emergency are payable for the
Eligible Expenses, minus the applicable Network Copayment or Coinsurance.
Extended Coverage during Total Disability
Extended Coverage for Total Disability described in the Certificate applies to Prescription Drug Products.
Pharmacy Charges for Additional Services
A pharmacy may charge you for services rendered by the pharmacy that are in addition to charges for the
Prescription Drug Product, for dispensing the drug or for prescription counseling. Services rendered by
the pharmacy for which additional charges are imposed are subject to the approval of the Board of
Pharmacy. A pharmacy must disclose to you the charges for the additional services and your out-ofpocket cost for those services prior to dispensing the Prescription Drug Product. A pharmacy may not
impose any additional charges for patient counseling or for other services required by the Board of
Pharmacy or State or federal law.
What You Must Pay
You are responsible for paying the applicable Copayment or Coinsurance described in the Benefit
Information table. You are not responsible for paying a Copayment or Coinsurance for Preventive Care
Medications.
The amount you pay for any of the following under this Rider will not be included in calculating any Outof-Pocket Maximum stated in your Certificate:

Copayments for Prescription Drug Products, including Specialty Prescription Drug Products.

Coinsurance for Prescription Drug Products, including Specialty Prescription Drug Products.

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.
3
Payment Information
Payment Term And Description Amounts
Copayment and Coinsurance
Copayment
Copayment for a Prescription Drug
Product at a Network or non-Network
Pharmacy is a specific dollar amount.
For Prescription Drug Products at a retail Network
Pharmacy, you are responsible for paying the lower of the
following:

The applicable Copayment or Coinsurance.
Coinsurance

Coinsurance for a Prescription Drug
Product at a Network Pharmacy is a
percentage of the Prescription Drug
Charge.
The Network Pharmacy's Usual and Customary
Charge for the Prescription Drug Product.
For Prescription Drug Products from a mail order Network
following:
Product at a non-Network Pharmacy is
a percentage of the Predominant
Reimbursement Rate.


The Prescription Drug Charge for that Prescription
Drug Product.
See the Copayments or Coinsurance stated in the Benefit
Information table for amounts.
Your Copayment or Coinsurance is
determined by the tier to which the
Prescription Drug List (PDL)
Management Committee has assigned
a Prescription Drug Product.
You are not responsible for paying a Copayment or
Coinsurance for Preventive Care Medications.
Special Programs: We may have
certain programs in which you may
receive a reduced or increased
Copayment or Coinsurance 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.
Prescription Drug Products
Prescribed by a Specialist Physician:
You may receive a reduced or
increased Copayment or Coinsurance
based on whether the Prescription Drug
Product was prescribed by a Specialist
Physician. You may access information
on which Prescription Drug Products are
subject to a reduced or increased
Copayment or Coinsurance through the
Internet at www.myuhc.com or by
4
calling Customer Care at the telephone
NOTE: The tier status of a Prescription
Drug Product can change periodically,
generally quarterly but no more than six
times per calendar year, based on the
Management Committee's periodic
tiering decisions. When that occurs, you
may pay more or less for a Prescription
Drug Product, depending on its tier
assignment. Please access
www.myuhc.com through the Internet or
call Customer Care at the telephone
number on your ID card for the most upto-date tier status.
5
Benefit Information
Description and Supply Limits
Benefit (The Amount We Pay)
Specialty Prescription Drug Products
The following supply limits apply.

As written by the provider, up to a
90-day supply of a Specialty
Prescription Drug Product,
subject to the drug
manufacturer's packaging size, or
based on supply limits.
Note: Some products are subject to
additional supply limits other than day
limits based on criteria we have
developed, subject to 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.
When a Specialty Prescription Drug
Product is packaged or designed to
deliver in a manner that provides more
than a consecutive 31-day supply, the
Copayment or Coinsurance that applies
will reflect the number of days
dispensed.
Supply limits apply to Specialty
Prescription Drug Products obtained at
a Network Pharmacy, a non-Network
Pharmacy, a mail order Network
Pharmacy or a Designated Specialty
Pharmacy.
You may determine whether a
Prescription Drug Product has been
assigned a maximum quantity level for
dispensing through the Internet at
Service at the telephone number on
your ID card.
Your Copayment or Coinsurance is determined by the tier
to which the Prescription Drug List (PDL) Management
Committee has assigned the Specialty Prescription Drug
Product. All Specialty Prescription Drug Products on the
Prescription Drug List are assigned to Tier-1, Tier-2 or Tier3. Please access www.myuhc.com through the Internet or
call Customer Care at the telephone number on your ID
card to determine tier status.
Network Pharmacy
For a Tier-1 Specialty Prescription Drug Product: 100% of
the Prescription Drug Charge after you pay a Copayment of
$10.00 per Prescription Order or Refill.
Non-Network Pharmacy
the Predominant Reimbursement Rate after you pay a
Copayment of $10.00 per Prescription Order or Refill.
Prescription Drugs from a Retail
Network Pharmacy

90-day supply of a Prescription
Drug Product, subject to the drug
Committee has assigned the Prescription Drug Product. All
Prescription Drug Products on the Prescription Drug List are
assigned to Tier-1, Tier-2 or Tier-3. Please access
www.myuhc.com through the Internet or call Customer Care
6

A one-cycle supply of a
contraceptive. You may obtain up
to three cycles at one time if you
pay a Copayment or Coinsurance
for each cycle supplied.
at the telephone number on your ID card to determine tier
status.
For a Tier-1 Prescription Drug Product: 100% of the
Prescription Drug Charge after you pay a Copayment of
When a Prescription Drug Product is
packaged or designed to deliver in a
manner that provides more than a
consecutive 31-day supply, the
dispensed.
Prescription Drugs from a Retail NonNetwork Pharmacy


status.
Predominant Reimbursement Rate after you pay a
7
your ID card.
Prescription Drug Products from a
Mail Order Network Pharmacy
The following supply limits apply:

consecutive 90-day supply of a
subject to the drug
based on supply limits. These
supply limits do not apply to
Specialty Prescription Drug
Products. Specialty Prescription
Drug Products from a mail order
Network Pharmacy are subject to
the supply limits stated above
under the heading Specialty
Prescription Drug Products.
status.
For up to a 90-day supply, we pay:
To maximize your Benefit, ask your
Physician to write your Prescription
Order or Refill for a 90-day supply, with
refills when appropriate. You will be
charged a mail order Copayment or
Coinsurance for any Prescription Orders
or Refills sent to the mail order
pharmacy regardless of the number-ofdays' supply written on the Prescription
Order or Refill. Be sure your Physician
writes your Prescription Order or Refill
for a 90-day supply, not a 30-day supply
with three refills.
your ID card.
8
This Rider to the Policy is issued to the Enrolling Group and provides Benefits for Prescription Drug
Products.
Because this Rider is part of 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 either the Certificate of Coverage (Certificate) in Section 9: Defined Terms or in this Rider in
Section 3: Defined Terms.
Insurance Company. When we use the words "you" and "your" we are referring to people who are
Covered Persons, as the term is defined in the Certificate in Section 9: Defined Terms.
NOTE: The Coordination of Benefits provision in the Certificate in Section 7: Coordination of Benefits
applies to Prescription Drug Products covered through this Rider. Benefits for Prescription Drug Products
will be coordinated with those of any other health plan in the same manner as Benefits for Covered
Health Services described in the Certificate.
RDR.RX.PLS.I.11.NJ
10
Introduction
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. Economic factors are
considered when two or more drugs are equivalent in terms of safety, effectiveness and clinical outcome.
Please refer to the Outpatient Prescription Drug Schedule of Benefits for more information concerning
Prior Authorization requirements.
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.
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.
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 the Certificate 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 and/or Coinsurance, and any deductible that
applies.
Submit your claim to the Pharmacy Benefit Manager claims address noted on your ID card.
Designated Specialty Pharmacies
If you require certain Specialty Prescription Drug Products for disease states such as:
RDR.RX.PLS.I.11.NJ
11

Hepatitis C

Multiple Sclerosis

Rheumatologic and related conditions (Rheumatoid Arthritis, Psoriatic Arthritis, Ankylosing
Spondylitis, Juvenile Rheumatoid Arthritis, Psoriasis)

Growth Hormone

Anemia, neutropenia, thrombocytopenia

Infertility

HIV/AIDS

Transplant

Oral Oncology

Pulmonary Arterial Hypertension

Osteoporosis

Cystic Fibrosis

Gaucher's Disease

Iron Overload

Endocrine disorders/Neurologic disorders such as infantile spasms

Hemophilia

Enzyme Deficiencies/Liposomal Storage Disorders
we may direct you to a Designated Specialty Pharmacy with whom we have an arrangement to provide
those Specialty Prescription Drug Products.
If you are directed to a Designated Specialty Pharmacy and you choose not to obtain your Prescription
Drug Product from a Designated Specialty Pharmacy, you will be subject to the non-Network Benefit for
that Prescription Drug Product.
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.
We may receive rebates for certain drugs included on the Prescription Drug List. We do not pass these
rebates on to you, nor are they taken into account in determining your Copayments and/or Coinsurance.
We, and a number of our affiliated entities, conduct business with various pharmaceutical manufacturers
separate and apart from this Outpatient Prescription Drug Rider. 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 Outpatient
RDR.RX.PLS.I.11.NJ
12
Prescription Drug Rider. 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.
Special Programs
You may qualify for certain programs in which you may receive an enhanced benefit based on your
adherence/compliance with medication or treatment regimens, and/or participation in health management
programs.
For certain qualifying medications, you may receive a $20 savings on your standard coinsurance if you
are taking the medication regularly and you refill your medication within 30 days of the date you are
scheduled to run out of medication. If you don't refill your medication within 30 days of the date you are
scheduled to run out of medication, you will pay your standard copayment. You may access further
information on these programs and which medications are included through the internet at
www.myuhc.com or by calling Customer Care at the telephone number on your ID Card. Please note this
program is subject to change without notice.
RDR.RX.PLS.I.11.NJ
13
Outpatient Prescription Drug Rider Table of Contents
Section 1: Benefits for Prescription Drug Products..............................15
Section 2: Exclusions ...............................................................................17
RDR.RX.PLS.I.11.NJ
14
Section 1: Benefits for Prescription Drug Products
Pharmacy and are subject to Copayments and/or Coinsurance or other payments that vary depending on
which of the tiers of the Prescription Drug List the Prescription Drug Product is listed. Refer to the
Outpatient Prescription Drug Schedule of Benefits for applicable Copayments and/or Coinsurance
requirements.
Benefits are provided for Specialty Prescription Drug Products.
If you require Specialty Prescription Drug Products, we may direct you to a Designated Specialty
Pharmacy with whom we have an arrangement to provide those Specialty Prescription Drug Products.
If you are directed to a Designated Specialty Pharmacy and you choose not to obtain your Specialty
Prescription Drug Product from a Designated Specialty Pharmacy, you will be subject to the non-Network
Benefit for that Specialty Prescription Drug Product.
Please see Section 3: Defined Terms for a full description of Specialty Prescription Drug Product and
Designated Specialty Pharmacy.
Refer to the Outpatient Prescription Drug Schedule of Benefits for details on Specialty Prescription Drug
Product supply limits.
Prescription Drugs from a Retail Network Pharmacy
Benefits are provided for Prescription Drug Products dispensed by a retail Network Pharmacy.
Refer to the Outpatient Prescription Drug 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 your Certificate, Section 5: How to File a Claim. We will not reimburse you for the difference
between the Allowable Expense 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 Outpatient Prescription Drug Schedule of Benefits for details on retail non-Network Pharmacy
supply limits.
Prescription Drug Products from a Mail Order Network Pharmacy
Benefits are provided for certain Prescription Drug Products dispensed by a mail order Network
Pharmacy.
Refer to the Outpatient Prescription Drug Schedule of Benefits for details on mail order Network
Pharmacy supply limits, Copayments or Coinsurance.
Supply Limits
RDR.RX.PLS.I.11.NJ
15
Benefits. For a single Copayment or Coinsurance, the Insured may receive a Prescription Drug Product
up to the stated supply limit. We will cover up to a consecutive 90-day supply of a Prescription Drug
Product, as written by the Physician, subject to the drug manufacturer’s packaging size, or based on
supply limits.
than a consecutive 31-day supply, the Copayment or Coinsurance that applies will reflect the number of
days dispensed.
NOTE: Some products are subject to additional supply limits other than day limits based on criteria that
the Company has developed, subject to its 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.
dispensing through the Internet at www.myuhc.com or by calling Customer Care at the telephone number
on your ID card.
RDR.RX.PLS.I.11.NJ
16
Section 2: Exclusions
Exclusions from coverage listed in the Certificate apply also to this Rider, except that any preexisting
condition exclusion in the Certificate is not applicable to this Rider. 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.
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. No prescribed drug shall be excluded on the basis that the drug has
not been approved by the United States Food and Drug Administration (USFDA) for which the drug
has been prescribed, if such drug is recognized as medically appropriate for the specific treatment
for which it has been prescribed by the American Hospital Formulary Service Drug Information, the
United States Pharmacopoeia Drug Information or a clinical study or review article in a major peer
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.
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. The failure of a self-employed person, limited liability partnership, limited liability company
or partnership to elect to obtain worker's compensation coverage for the self-employed person, the
limited liability partners, the limited liability company members or the partners shall not affect
benefits available under this rider.
8.
Any product dispensed for the purpose of appetite suppression or weight loss.
9.
A Pharmaceutical Product for which Benefits are provided in your Certificate. This exclusion does
not apply to Depo Provera and other injectable 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 of Prescription Drug Products.
13.
Medications used for cosmetic purposes except for coverage for newborn children including the
necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.
RDR.RX.PLS.I.11.NJ
17
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.
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 for smoking cessation.
17.
Compounded drugs that do not contain at least one ingredient that has been approved by the U.S.
Food and Drug Administration (FDA) and requires a Prescription Order or Refill. Compounded
drugs that are available as a similar commercially available Prescription Drug Product.
(Compounded drugs that contain at least one ingredient that requires a Prescription Order or Refill
are assigned to Tier-3.)
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. Prescription Drug Products that are available in over-the-counter
form or comprised of components that are available in over-the-counter form or equivalent unless
the prescribing health care provider certifies the medical necessity of the drug. 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.
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.
20.
Growth hormone for children with familial short stature (short stature based upon heredity and not
caused by a diagnosed medical condition).
21.
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 as
required by state mandate.
RDR.RX.PLS.I.11.NJ
18
Brand-name - a Prescription Drug Product which is manufactured and marketed under a trademark or
name by a specific drug manufacturer.
Chemically Equivalent - when Prescription Drug Products contain the same active ingredient.
Designated Specialty Pharmacy - a pharmacy that has entered into an agreement with us or with an
organization contracting on our behalf, to provide specific Prescription Drug Products, including, but not
limited to, Specialty Prescription Drug Products. The fact that a pharmacy is a Network Pharmacy does
not mean that it is a Designated Specialty Pharmacy.
Generic - a Prescription Drug Product that is Chemically Equivalent to a Brand-name drug.
Infertility - failure to achieve a Pregnancy after a year of regular unprotected intercourse if the woman is
under age 35, or after six months if the woman is over age 35. In addition, in order to be eligible for
Benefits, the Covered Person must also:

Be under age 44, if female.

Have infertility that is not related to voluntary sterilization or failed reversal of voluntary sterilization.
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.

six months following date the Prescription Drug Product or new dosage form is approved by the
U.S. Food and Drug Administration.
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
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:
RDR.RX.PLS.I.11.NJ
19

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; and

glucose monitors.
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 and that are
payable at 100% of the cost (without application of any Copayment, Coinsurance, Annual Deductible,
Annual Drug Deductible or Specialty Prescription Drug Product Annual Deductible) as required by
applicable law under any of the following:



You may determine whether a drug is a Preventive Care Medication through the internet at
Specialty Prescription Drug Product - Prescription Drug Products that are generally high cost, selfadministered biotechnology drugs used to treat patients with certain illnesses. You may access a
complete list of Specialty Prescription 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.
RDR.RX.PLS.I.11.NJ
20
As described in this addendum, Benefits for oral chemotherapeutic agents are modified in the Outpatient
Prescription Drug Rider and Outpatient Prescription Drug Schedule of Benefits as stated below.
Because this addendum is part of a legal document (the group Policy), we want to give you information
We have defined these words in the Certificate of Coverage (Certificate) in Section 9: Defined Terms and
in the Outpatient Prescription Drug Rider.
Benefits for Oral Chemotherapeutic Agents
Oral chemotherapeutic agent Prescription Drug Products from a retail or mail order Network Pharmacy
are provided at 100% of the Prescription Drug Charge (without application of any Copayment,
Coinsurance, Annual Deductible or Annual Drug Deductible, as applicable) per Prescription Order or
Refill, regardless of tier placement. This includes oral chemotherapeutic agents that are Specialty
RXADD_ORALCHEMO.I.0711NJ
1
Act (PPACA)
IMPORTANT NOTICE: If you have a dependent child whose coverage ended or who was denied
coverage (or was not eligible for coverage) because dependent coverage of children was not available up
to age 26, you may have the right to enroll that dependent under a special dependent child enrollment
period. This right applies as of the first day of the first plan year beginning on or after September 23, 2010
and your employer (or enrolling group) must provide you with at least a 30 day enrollment period. If you
are adding a dependent child during this special enrollment period and have a choice of coverage options
under the plan, you will be allowed to change options. This child special open enrollment may coincide
with your annual open enrollment, if you have one. Please contact your employer or group plan
administrator for more information.
IMPORTANT NOTICE: If coverage or benefits for you or a dependent ended due to reaching a lifetime
limit, be advised that a lifetime limit on the dollar value of benefits no longer applies. If you are covered
under the plan, you are once again eligible for benefits. Additionally, if you are not enrolled in the plan, but
are still eligible for coverage, then you will have a 30 day opportunity to request enrollment. This 30 day
enrollment opportunity will begin no later than the first day of the first plan year beginning on or after
September 23, 2010. This 30 day enrollment period may coincide with your annual open enrollment, if
you have one. Please contact your employer or group health plan administrator for more information.
I
There are changes in Federal law which may impact coverage and Benefits stated in the Certificate of
Coverage (Certificate) and Schedule of Benefits. A summary of those changes and the dates the changes
are effective appear below.
Patient Protection and Affordable Care Act (PPACA)
Effective for policies that are new or renewing on or after September 23, 2010, the requirements listed
below apply.

Lifetime limits on the dollar amount of essential benefits available to you under the terms of your
plan are no longer permitted. Essential benefits include the following:
Ambulatory patient services; emergency services, hospitalization; maternity and newborn care,
mental health and substance use disorder services (including behavioral health treatment);
prescription drugs; rehabilitative and habilitative services and devices; laboratory services;
preventive and wellness services and chronic disease management; and pediatric services,
including oral and vision care.

On or before the first day of the first plan year beginning on or after September 23, 2010, the
enrolling group will provide a 30 day enrollment period for those individuals who are still eligible
under the plan's eligibility terms but whose coverage ended by reason of reaching a lifetime limit on
the dollar value of all benefits.

Essential benefits for plan years beginning prior to January 1, 2014 can only be subject to
restricted annual limits. Restricted annual limits for each person covered under the plan may be no
less than the following:

For plan or policy years beginning on or after September 23, 2010 but before September 23,
2011, $750,000.

2012, $1,250,000.

For plan or policy years beginning on or after September 23, 2012 but before January 1,
2014, $2,000,000.

Any pre-existing condition exclusions (including denial of benefits or coverage) will not apply to
covered persons under the age of 19.

Coverage for enrolled dependent children is no longer conditioned upon full-time student status or
other dependency requirements and will remain in place until the child's 26th birthday. If you have
a grandfathered plan, the enrolling group is not required to extend coverage to age 26 if the child is
eligible to enroll in an eligible employer-sponsored health plan (as defined by law). Under the
PPACA a plan generally is "grandfathered" if it was in effect on March 23, 2010 and there are no
substantial changes in the benefit design as described in the Interim Final Rule on Grandfathered
Health Plans.
enrolling group will provide a 30 day dependent child special open enrollment period for dependent
children who are not currently enrolled under the policy and who have not yet reached age 26.
During this dependent child special open enrollment period, subscribers who are adding a
dependent child and who have a choice of coverage options will be allowed to change options.

If your plan includes coverage for enrolled dependent children beyond the age of 26, which is
conditioned upon full-time student status, the following applies:
II
Coverage for enrolled dependent children who are required to maintain full-time student status in
order to continue eligibility under the policy is subject to the statute known as Michelle's Law. This
law amends ERISA, the Public Health Service Act, and the Internal Revenue Code and requires
group health plans, which provide coverage for dependent children who are post-secondary school
students, to continue such coverage if the student loses the required student status because he or
she must take a medically necessary leave of absence from studies due to a serious illness or
Injury.



If you do not have a grandfathered plan, in-network benefits for preventive care services described
below will be paid at 100%, and not subject to any deductible, coinsurance or copayment. If you
have pharmacy benefit coverage, your plan may also be required to cover preventive care
medications that are obtained at a network pharmacy at 100%, and not subject to any deductible,
coinsurance or copayment, as required by applicable law under any of the following:



screenings provided for in the comprehensive guidelines supported by the Health Resources
and Services Administration.

Retroactive rescission of coverage under the policy is permitted, with 30 days advance written
notice, only in the following two circumstances:

The individual performs an act, practice or omission that constitutes fraud.

The individual makes an intentional misrepresentation of a material fact.
Other changes provided for under the PPACA do not impact your plan because your plan already
contains these benefits. These include:

Direct access to OB/GYN care without a referral or authorization requirement.

The ability to designate a pediatrician as a primary care physician (PCP) if your plan requires
a PCP designation.

Prior authorization is not required before you receive services in the emergency department
of a hospital.
If you seek emergency care from out-of-network providers in the emergency department of a
hospital your cost sharing obligations (copayments/coinsurance) will be the same as would
be applied to care received from in-network providers.
Some Important Information about Appeal and External Review Rights under
PPACA
If you are enrolled in a non-grandfathered plan with an effective date or plan year anniversary on or after
September 23, 2010, the Patient Protection and Affordable Care Act of 2010 (PPACA), as amended, sets
forth new and additional internal appeal and external review rights beyond those that some plans may
have previously offered. Also, certain grandfathered plans are complying with the additional internal
appeal and external review rights provisions on a voluntary basis. Please refer to your benefit plan
documents, including amendments and notices, or speak with your employer or UnitedHealthcare for
III
more information on the appeal rights available to you. (Also, please refer to the Claims and Appeal
Notice section of this document.)
What if I receive a denial, and need help understanding it? Please call UnitedHealthcare at the
number listed on the back of your health plan ID card.
What if I don't agree with the denial? You have a right to appeal any decision to not pay for an item or
service.
How do I file an appeal? The initial denial letter or Explanation of Benefits that you receive from
UnitedHealthcare will give you the information and the timeframe to file an appeal.
What if my situation is urgent? If your situation is urgent, your review will be conducted as quickly as
possible. If you believe your situation is urgent, you may request an expedited review, and, if applicable,
file an external review at the same time. For help call UnitedHealthcare at the number listed on the back
of your health plan ID card.
Generally, an urgent situation is when your health may be in serious jeopardy. Or when, in the opinion of
your doctor, you may be experiencing severe pain that cannot be adequately controlled while you wait for
a decision on your appeal.
Who may file an appeal? Any member or someone that member names to act as an authorized
representative may file an appeal. For help call UnitedHealthcare at the number listed on the back of your
health plan ID card.
Can I provide additional information about my claim? Yes, you may give us additional information
supporting your claim. Send the information to the address provided in the initial denial letter or
Explanation of Benefits.
Can I request copies of information relating to my claim? Yes. There is no cost to you for these
copies. Send your request to the address provided in the initial denial letter or Explanation of Benefits.
What happens if I don't agree with the outcome of my appeal? If you appeal, we will review our
decision. We will also send you our written decision within the time allowed. If you do not agree with the
decision, you may be able to request an external review of your claim by an independent third party. They
will review the denial and issue a final decision.
If I need additional help, what should I do? For questions on your appeal rights, you may call
UnitedHealthcare at the number listed on the back of your health plan ID card. You may also contact the
support groups listed below.
Are verbal translation services available to me during an appeal? Yes. Contact UnitedHealthcare at
the number listed on the back of your health plan ID card. Ask for verbal translation services for your
questions.
Is there other help available to me? For questions about appeal rights, an unfavorable benefit decision,
or for help, you may also contact the Employee Benefits Security Administration at 1-866-444-EBSA
(3272). Your state consumer assistance program may also be able to help you.
For information on appeals and other PPACA regulations, visit www.healthcare.gov.
Mental Health/Substance Use Disorder Parity
Effective for Policies that are new or renewing on or after July 1, 2010, Benefits are subject to final
regulations supporting the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Benefits for
mental health conditions and substance use disorder conditions that are Covered Health Services under
the Policy must be treated in the same manner and provided at the same level as Covered Health
Services for the treatment of other Sickness or Injury. Benefits for Mental Health Services and Substance
Use Disorder Services are not subject to any annual maximum benefit limit (including any day, visit or
dollar limit).
IV
MHPAEA requires that the financial requirements for coinsurance and copayments for mental health and
substance use disorder conditions must be no more restrictive than those coinsurance and copayment
requirements for substantially all medical/surgical benefits. MHPAEA requires specific testing to be
applied to classifications of benefits to determine the impact of these financial requirements on mental
health and substance use disorder benefits. Based upon the results of that testing, it is possible that
coinsurance or copayments that apply to mental health conditions and substance use disorder conditions
in your benefit plan may be reduced.
V
As required by the Women's Health and Cancer Rights Act of 1998, Benefits under the Policy are
provided for mastectomy, including reconstruction and surgery to achieve symmetry between the breasts,
prostheses, and complications resulting from a mastectomy (including lymphedema).
If you are receiving Benefits in connection with a mastectomy, Benefits are also provided for the following
Covered Health Services, as you determine appropriate with your attending Physician:

All stages of reconstruction of the breast on which the mastectomy was performed;

Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

Prostheses and treatment of physical complications of the mastectomy, including lymphedema.
The amount you must pay for such Covered Health Services (including Copayments, Coinsurance and
any Annual Deductible) are the same as are required for any other Covered Health Service. Limitations
on Benefits are the same as for any other Covered Health Service.
Protection Act
Under Federal law, group health plans and health insurance issuers offering group health insurance
coverage generally may not restrict Benefits for any Hospital length of stay in connection with childbirth
for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours
following a delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the
attending provider (e.g. your Physician, nurse midwife, or physician assistant), after consultation with the
mother, discharges the mother or newborn earlier.
Also, under Federal law, plans and issuers may not set the level of Benefits or out-of-pocket costs so that
any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or
newborn than any earlier portion of the stay.
In addition, a plan or issuer may not, under Federal law, require that a Physician or other health care
provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to
use certain providers or facilities, or to reduce your out-ofpocket costs, you may be required to obtain
precertification. For information on precertification, contact your issuer.
VI
This Notice is provided to you in order to describe our responsibilities under Federal law for
making benefit determinations and your right to appeal adverse benefit determinations. To the
extent that state law provides you with more generous timelines or opportunities for appeal, those
rights also apply to you. Please refer to your benefit documents for information about your rights
under state law.
Benefit Determinations
Post-service Claims
received. If your post-service claim is denied, you will receive a written notice from us within 30 days of
receipt of the claim, as long as all needed information was provided with the claim. We will notify you
within this 30 day period if additional information is needed to process the claim, and may request a one
time extension not longer than 15 days and pend your claim until all information is received.
Once notified of the extension, you then have 45 days to provide this information. If all of the needed
information is received within the 45-day time frame, and the claim is denied, we will notify you of the
denial within 15 days after the information is received. If you don't provide the needed information within
the 45-day period, your claim will be denied.
A denial notice will explain the reason for denial, refer to the part of the plan on which the denial is based,
and provide the claim appeal procedures.
If you have prescription drug Benefits and are asked to pay the full cost of a prescription when you fill it at
a retail or mail-order pharmacy, and if you believe that it should have been paid under the Policy, you
may submit a claim for reimbursement in accordance with the applicable claim filing procedures. If you
pay a Copayment and believe that the amount of the Copayment was incorrect, you also may submit a
claim for reimbursement in accordance with the applicable claim filing procedures. When you have filed a
claim, your claim will be treated under the same procedures for post-service group health plan claims as
described in this section.
Pre-service requests for Benefits are those requests that require notification or approval prior to receiving
medical care. If you have a pre-service request for Benefits, and it was submitted properly with all needed
information, you will receive written notice of the decision from us within 15 days of receipt of the request.
If you filed a pre-service request for Benefits improperly, we will notify you of the improper filing and how
to correct it within five days after the pre-service request for Benefits was received. If additional
information is needed to process the pre-service request, we will notify you of the information needed
within 15 days after it was received, and may request a one time extension not longer than 15 days and
pend your request until all information is received. Once notified of the extension you then have 45 days
to provide this information. If all of the needed information is received within the 45-day time frame, we
will notify you of the determination within 15 days after the information is received. If you don't provide the
needed information within the 45-day period, your request for Benefits will be denied. A denial notice will
explain the reason for denial, refer to the part of the plan on which the denial is based, and provide the
appeal procedures.
If you have prescription drug Benefits and a retail or mail order pharmacy fails to fill a prescription that
you have presented, you may file a pre-service health request for Benefits in accordance with the
applicable claim filing procedure. When you have filed a request for Benefits, your request will be treated
under the same procedures for pre-service group health plan requests for Benefits as described in this
section.
VII
Urgent Requests for Benefits that Require Immediate Attention
Urgent requests for Benefits are those that require notification or a benefit determination prior to receiving
medical care, where a delay in treatment could seriously jeopardize your life or health, or the ability to
regain maximum function or, in the opinion of a Physician with knowledge of your medical condition, could
cause severe pain. In these situations, you will receive notice of the benefit determination in writing or
electronically within 72 hours after we receive all necessary information, taking into account the
seriousness of your condition.
If you filed an urgent request for Benefits improperly, we will notify you of the improper filing and how to
correct it within 24 hours after the urgent request was received. If additional information is needed to
process the request, we will notify you of the information needed within 24 hours after the request was
received. You then have 48 hours to provide the requested information.
You will be notified of a benefit determination no later than 48 hours after:

Our receipt of the requested information; or

The end of the 48-hour period within which you were to provide the additional information, if the
information is not received within that time.
Concurrent Care Claims
If an on-going course of treatment was previously approved for a specific period of time or number of
treatments, and your request to extend the treatment is an urgent request for Benefits as defined above,
your request will be decided within 24 hours, provided your request is made at least 24 hours prior to the
end of the approved treatment. We will make a determination on your request for the extended treatment
within 24 hours from receipt of your request.
If your request for extended treatment is not made at least 24 hours prior to the end of the approved
treatment, the request will be treated as an urgent request for Benefits and decided according to the
timeframes described above. If an on-going course of treatment was previously approved for a specific
period of time or number of treatments, and you request to extend treatment in a non-urgent
circumstance, your request will be considered a new request and decided according to post-service or
pre-service timeframes, whichever applies.
Questions or Concerns about Benefit Determinations
If you have a question or concern about a benefit determination, you may informally contact our Customer
Care department before requesting a formal appeal. If the Customer Care representative cannot resolve
the issue to your satisfaction over the phone, you may submit your question in writing. However, if you
are not satisfied with a benefit determination as described above, you may appeal it as described below,
without first informally contacting a Customer Care representative. If you first informally contact our
Customer Care department and later wish to request a formal appeal in writing, you should again contact
Customer Care and request an appeal. If you request a formal appeal, a Customer Care representative
will provide you with the appropriate address.
If you are appealing an urgent claim denial, please refer to Urgent Appeals that Require Immediate Action
below and contact our Customer Care department immediately.
If you disagree with a pre-service request for Benefits determination or post-service claim determination
or a rescission of coverage determination after following the above steps, you can contact us in writing to
formally request an appeal.
VIII
Your request should include:





Your first appeal request must be submitted to us within 180 days after you receive the claim denial.
Appeal Process
and free of charge, you have the right to reasonable access to and copies of all documents, records, and

conducted and you will be notified of the decision within 15 days from receipt of a request for
appeal of a denied request for Benefits. The second level appeal will be conducted and you will be
notified of the decision within 15 days from receipt of a request for review of the first level appeal
decision.

you will be notified of the decision within 30 days from receipt of a request for appeal of a denied
claim. The second level appeal will be conducted and you will be notified of the decision within 30
days from receipt of a request for review of the first level appeal decision.
Action below.
If you are not satisfied with the first level appeal decision, you have the right to request a second level
appeal. Your second level appeal request must be submitted to us within 60 days from receipt of the first
level appeal decision.
Please note that our decision is based only on whether or not Benefits are available under the Policy for
the proposed treatment or procedure. We don't determine whether the pending health service is
necessary or appropriate. That decision is between you and your Physician.
Your appeal may require immediate action if a delay in treatment could significantly increase the risk to
your health, or the ability to regain maximum function, or cause severe pain. In these urgent situations:
IX

as possible.

X
Medical Information Privacy Notice
This notice describes how medical information about you may be used and disclosed and how
you can get access to this information. Please review it carefully.
We* are required by law to protect the privacy of your health information. We are also required to send
you this notice, which explains how we may use information about you and when we can give out or
"disclose" that information to others. You also have rights regarding your health information that are
described in this notice. We are required by law to abide by the terms of this notice.
The terms "information" or "health information" in this notice include any information we maintain that
reasonably can be used to identify you and that relates to your physical or mental health condition, the
provision of health care to you, or the payment for such health care.
We have the right to change our privacy practices and the terms of this notice. If we make a material
change to our privacy practices, we will provide to you a revised notice by direct mail or electronically as
permitted by applicable law. In all cases, we will post the revised notice on our website www.myuhc.com.
We reserve the right to make any revised or changed notice effective for information we already have and
for information that we receive in the future.
*For purposes of this Notice of Privacy Practices, "we" or "us" refers to the following health plans that are
affiliated with UnitedHealth Group:
ACN Group of California, Inc.; All Savers Insurance Company; All Savers Life Insurance Company of
California; American Medical Security Life Insurance Company; AmeriChoice of Connecticut, Inc.;
AmeriChoice of Georgia, Inc.; AmeriChoice of New Jersey, Inc.; Arizona Physicians IPA, Inc.; Citrus
Health Care, Inc.; Dental Benefit Providers of California, Inc.; Dental Benefit Providers of Illinois, Inc.;
Evercare of Arizona, Inc.; Evercare of New Mexico, Inc.; Evercare of Texas, LLC; Golden Rule Insurance
Company; Health Plan of Nevada, Inc.; MAMSI Life and Health Insurance Company; MD-Individual
Practice Association, Inc.; Midwest Security Life Insurance Company; National Pacific Dental, Inc.;
Neighborhood Health Partnership, Inc.; Nevada Pacific Dental; Optimum Choice, Inc.; Oxford Health
Insurance, Inc.; Oxford Health Plans (CT), Inc.; Oxford Health Plans (NJ), Inc.; Oxford Health Plans (NY),
Inc.; PacifiCare Life and Health Insurance Company; PacifiCare Life Assurance Company; Physicians
Health Choice of Texas, LLC; Sierra Health & Life Insurance Co., Inc.; UHC of California; U.S. Behavioral
Health Plan, California; Unimerica Insurance Company; Unimerica Life Insurance Company of New York;
Unison Family Health Plan of Pennsylvania, Inc.; Unison Health Plan of Delaware, Inc.; Unison Health
Plan of Pennsylvania, Inc.; Unison Health Plan of Tennessee, Inc.; Unison Health Plan of the Capital
Area, Inc.; United Behavioral Health; UnitedHealthcare Benefits of Texas, Inc.; UnitedHealthcare
Community Plan of Ohio, Inc.; UnitedHealthcare Insurance Company; UnitedHealthcare Insurance
Company of Illinois; UnitedHealthcare Insurance Company of New York; UnitedHealthcare Insurance
Company of the River Valley; UnitedHealthcare Insurance Company of Ohio; UnitedHealthcare of
Alabama, Inc.; UnitedHealthcare of Arizona, Inc.; UnitedHealthcare of Arkansas, Inc.; UnitedHealthcare of
Colorado, Inc.; UnitedHealthcare of Florida, Inc.; UnitedHealthcare of Georgia, Inc.; UnitedHealthcare of
Illinois, Inc.; UnitedHealthcare of Kentucky, Ltd.; UnitedHealthcare of Louisiana, Inc.; UnitedHealthcare of
the Mid-Atlantic, Inc.; UnitedHealthcare of the Great Lakes Health Plan, Inc.; UnitedHealthcare of the
Midlands, Inc.; UnitedHealthcare of the Midwest, Inc.; United HealthCare of Mississippi, Inc.;
UnitedHealthcare of New England, Inc.; UnitedHealthcare of New York, Inc.; UnitedHealthcare of North
Carolina, Inc.; UnitedHealthcare of Ohio, Inc.; UnitedHealthcare of Oklahoma, Inc.; UnitedHealthcare of
Oregon, Inc.; UnitedHealthcare of Pennsylvania, Inc.; UnitedHealthcare of South Carolina, Inc.;
UnitedHealthcare of Texas, Inc.; UnitedHealthcare of Utah, Inc.; UnitedHealthcare of Washington, Inc.;
UnitedHealthcare of Wisconsin, Inc.; UnitedHealthcare Plan of the River Valley, Inc.
XI
How We Use or Disclose Information
We must use and disclose your health information to provide that information:

To you or someone who has the legal right to act for you (your personal representative) in order to
administer your rights as described in this notice; and

To the Secretary of the Department of Health and Human Services, if necessary, to make sure
your privacy is protected.
We have the right to use and disclose health information for your treatment, to pay for your health care
and to operate our business. For example, we may use or disclose your health information:

For Payment of premiums due us, to determine your coverage, and to process claims for health
care services you receive, including for subrogation or coordination of other benefits you may have.
For example, we may tell a doctor whether you are eligible for coverage and what percentage of
the bill may be covered.

For Treatment. We may use or disclose health information to aid in your treatment or the
coordination of your care. For example, we may disclose information to your physicians or hospitals
to help them provide medical care to you.

For Health Care Operations. We may use or disclose health information as necessary to operate
and manage our business activities related to providing and managing your health care coverage.
For example, we might talk to your physician to suggest a disease management or wellness
program that could help improve your health or we may analyze data to determine how we can
improve our services.

To Provide You Information on Health Related Programs or Products such as alternative
medical treatments and programs or about health-related products and services, subject to limits
imposed by law.

For Plan Sponsors. If your coverage is through an employer sponsored group health plan, we
may share summary health information and enrollment and disenrollment information with the plan
sponsor. In addition, we may share other health information with the plan sponsor for plan
administration if the plan sponsor agrees to special restrictions on its use and disclosure of the
information in accordance with federal law.

For Reminders. We may use or disclose health information to send you reminders about your
benefits or care, such as appointment reminders with providers who provide medical care to you.
We may use or disclose your health information for the following purposes under limited circumstances:

As Required by Law. We may disclose information when required to do so by law.

To Persons Involved With Your Care. We may use or disclose your health information to a
person involved in your care or who helps pay for your care, such as a family member, when you
are incapacitated or in an emergency, or when you agree or fail to object when given the
opportunity. If you are unavailable or unable to object, we will use our best judgment to decide if
the disclosure is in your best interests.

For Public Health Activities such as reporting or preventing disease outbreaks.

For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that
are authorized by law to receive such information, including a social service or protective service
agency.

For Health Oversight Activities to a health oversight agency for activities authorized by law, such
as licensure, governmental audits and fraud and abuse investigations.
XII

For Judicial or Administrative Proceedings such as in response to a court order, search warrant
or subpoena.

For Law Enforcement Purposes. We may disclose your health information to a law enforcement
official for purposes such as providing limited information to locate a missing person or report a
crime.

To Avoid a Serious Threat to Health or Safety to you, another person or the public by, for
example, disclosing information to public health agencies or law enforcement authorities, or in the
event of an emergency or natural disaster.

For Specialized Government Functions such as military and veteran activities, national security
and intelligence activities, and the protective services for the President and others.

For Workers' Compensation as authorized by, or to the extent necessary to comply with, state
workers compensation laws that govern job-related injuries or illness.

For Research Purposes such as research related to the evaluation of certain treatments or the
prevention of disease or disability, if the research study meets privacy law requirements.

To Provide Information Regarding Decedents. We may disclose information to a coroner or
medical examiner to identify a deceased person, determine a cause of death, or as authorized by
law. We may also disclose information to funeral directors as necessary to carry out their duties.

For Organ Procurement Purposes. We may use or disclose information to entities that handle
procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and
transplantation.

To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional
institution or under the custody of a law enforcement official, but only if necessary (1) for the
institution to provide you with health care; (2) to protect your health and safety or the health and
safety of others; or (3) for the safety and security of the correctional institution.

To Business Associates that perform functions on our behalf or provide us with services if the
information is necessary for such functions or services. Our business associates are required,
under contract with us, to protect the privacy of your information and are not allowed to use or
disclose any information other than as specified in our contract.

For Data Breach Notification Purposes. We may use your contact information to provide legallyrequired notices of unauthorized acquisition, access, or disclosure of your health information. We
may send notice directly to you or provide notice to the sponsor of your plan through which you
receive coverage.
Additional Restrictions on Use and Disclosure
Certain federal and state laws may require special privacy protections that restrict the use and disclosure
of certain health information, including highly confidential information about you. "Highly confidential
information" may include confidential information under Federal laws governing alcohol and drug abuse
information and genetic information as well as state laws that often protect the following types of
information:

HIV/AIDS;

Mental health;

Genetic tests;

Alcohol and drug abuse;
XIII

Sexually transmitted diseases and reproductive health information; and

Child or adult abuse or neglect, including sexual assault.
If a use or disclosure of health information described above in this notice is prohibited or materially limited
by other laws that apply to us, it is our intent to meet the requirements of the more stringent law. Attached
to this notice is a summary of federal and state laws on use and disclosure of certain types of medical
information.
Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose
your health information only with a written authorization from you. Once you give us authorization to
release your health information, we cannot guarantee that the person to whom the information is provided
will not disclose the information. You may take back or "revoke" your written authorization at anytime in
writing, except if we have already acted based on your authorization. To find out where to mail your
written authorization and how to revoke an authorization, contact the phone number listed on the back of
your ID card.
What Are Your Rights
The following are your rights with respect to your health information:

You have the right to ask to restrict uses or disclosures of your information for treatment,
payment, or health care operations. You also have the right to ask to restrict disclosures to family
members or to others who are involved in your health care or payment for your health care. We
may also have policies on dependent access that authorize your dependents to request certain
restrictions. Please note that while we will try to honor your request and will permit requests
consistent with our policies, we are not required to agree to any restriction.

You have the right to ask to receive confidential communications of information in a different
manner or at a different place (for example, by sending information to a P.O. Box instead of your
home address). We will accommodate reasonable requests where a disclosure of all or part of your
health information otherwise could endanger you. We will accept verbal requests to receive
confidential communications, but requests to modify or cancel a previous confidential
communication request must be made in writing. Mail your request to the address listed below.

You have the right to see and obtain a copy of health information that may be used to make
decisions about you such as claims and case or medical management records. You also may in
some cases receive a summary of this health information. You must make a written request to
inspect and copy your health information. Mail your request to the address listed below. In certain
limited circumstances, we may deny your request to inspect and copy your health information. We
may charge a reasonable fee for any copies. If we deny your request, you have the right to have
the denial reviewed. If we maintain an electronic health record containing your health information,
when and if we are required by law, you will have the right to request that we send a copy of your
health information in an electronic format to you or to a third party that you identify. We may charge
a reasonable fee for sending the electronic copy of your health information.

You have the right to ask to amend information we maintain about you if you believe the health
information about you is wrong or incomplete. Your request must be in writing and provide the
reasons for the requested amendment. Mail your request to the address listed below. If we deny
your request, you may have a statement of your disagreement added to your health information.

You have the right to receive an accounting of certain disclosures of your information made by
us during the six years prior to your request. This accounting will not include disclosures of
information made: (i) prior to April 14, 2003; (ii) for treatment, payment and health care operations
purposes; (iii) to you or pursuant to your authorization; (iv) to correctional institutions or law
enforcement officials; and (v) other disclosures for which federal law does not require us to provide
an accounting.
XIV

You have the right to a paper copy of this notice. You may ask for a copy of this notice at any
time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper
copy of this notice. You also may obtain a copy of this notice at our website, www.myuhc.com.
Exercising Your Rights

Contacting your Health Plan. If you have any questions about this notice or want to exercise any
of your rights, please call the toll-free phone number on the back of your ID card or you may
contact the UnitedHealth Group Customer Call Center at 866-633-2446.

Submitting a Written Request. Mail to us your written requests for modifying or cancelling a
confidential communication, for copies of your records, or for amendments to your record, at the
following address:
UnitedHealthcare
Customer Service - Privacy Unit
PO Box 740815
Atlanta, GA 30374-0815

Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint
with us at the address listed above.
You may also notify the Secretary of the U.S. Department of Health and Human Services of your
complaint. We will not take any action against you for filing a complaint.
XV
This notice describes how financial information about you may be used and disclosed and how
We** are committed to maintaining the confidentiality of your personal financial information. For the
purposes of this notice, "personal financial information" means information about an enrollee or an
applicant for health care coverage that identifies the individual, is not generally publicly available and is
collected from the individual or is obtained in connection with providing health care coverage to the
individual.
Information We Collect
We collect personal financial information about you from the following sources:

Information we receive from you on applications or other forms, such as name, address, age,
medical information and Social Security number.

Information about your transactions with us, our affiliates or others, such as premium payment and
claims history.

Information from consumer reports.
Disclosure of Information
We do not disclose personal financial information about our enrollees or former enrollees to any third
party, except as required or permitted by law. For example, in the course of our general business
practices, we may, as permitted by law, disclose any of the personal financial information that we collect
about you, without your authorization, to the following types of institutions:

To our corporate affiliates, which include financial service providers, such as other insurers, and
non-financial companies, such as data processors.

To nonaffiliated companies for our everyday business purposes, such as to process your
transactions, maintain your account(s), or respond to court orders and legal investigations.

To nonaffiliated companies that perform services for us, including sending promotional
communications on our behalf.
For purposes of this Financial Information Privacy Notice, "we" or "us" refers to the entities listed on the
first page of the Health Plan Notices of Privacy Practices, plus the following UnitedHealthcare affiliates:
AmeriChoice Health Services, Inc.; DBP Services of New York IPA, Inc.; DCG Resource Options, LLC;
Dental Benefit Providers, Inc.; Dental Benefit Providers of California, Inc.; Dental Benefit Providers of
Illinois, Inc.; Disability Consulting Group, LLC; HealthAllies, Inc.; MAMSI Insurance Resources, LLC;
Managed Physical Network, Inc.; Mid Atlantic Medical Services, LLC; National Pacific Dental, Inc.;
Nevada Pacific Dental; OneNet PPO, LLC; Oxford Benefit Management, Inc.; Oxford Health Plans LLC;
PacifiCare Health Plan Administrators, Inc.; ProcessWorks, Inc.; Spectera, Inc.; Spectera of New York,
IPA, Inc.; UMR, Inc.; Unimerica Insurance Company; Unimerica Life Insurance Company of New York;
Unison Administrative Services, LLC; United Behavioral Health of New York I.P.A., Inc.; United
HealthCare Services, Inc.; UnitedHealth Advisors, LLC; UnitedHealthcare Service LLC; UnitedHealthcare
Services Company of the River Valley, Inc.; UnitedHealthOne Agency, Inc. This Financial Information
Privacy Notice only applies where required by law. Specifically, it does not apply to (1) health care
insurance products offered in Nevada by Health Plan of Nevada, Inc. and Sierra Health and Life
Insurance Company, Inc.; or (2) other UnitedHealth Group health plans in states that provide exceptions
for HIPAA covered entities or health insurance products.
XVI
Confidentiality and Security
We restrict access to personal financial information about you to our employees and service providers
who are involved in administering your health care coverage and providing services to you. We maintain
physical, electronic and procedural safeguards in compliance with state and federal standards to guard
your personal financial information. We conduct regular audits to help ensure appropriate and secure
handling and processing of our enrollees' information.
Questions about this Notice
If you have any questions about this notice, please call the toll-free phone number on the back of your ID
card or you may contact the UnitedHealth Group Customer Call Center at 866-633-2446.
XVII
UnitedHealth Group
Amendments
The first part of this Notice, which provides our privacy practices for Medical Information, describes how
we may use and disclose your health information under federal privacy rules. There are other laws that
may limit our rights to use and disclose your health information beyond what we are allowed to do under
the federal privacy rules. The purpose of the charts below is to:

Show the categories of health information that are subject to these more restrictive laws.

Give you a general summary of when we can use and disclose your health information without your
consent.
If your written consent is required under the more restrictive laws, the consent must meet the particular
rules of the applicable federal or state law.
Summary of Federal Laws
Alcohol & Drug Abuse Information
We are allowed to use and disclose alcohol and drug abuse information that is protected by federal
law only (1) in certain limited circumstances, and/or disclose only (2) to specific recipients.
Genetic Information
We are not allowed to use genetic information for underwriting purposes.
Summary of State Laws
General Health Information
We are allowed to disclose general health
information only (1) under certain limited
circumstances, and /or (2) to specific recipients.
CA, NE, PR, RI, VT, WA, WI
HMOs must give enrollees an opportunity to
approve or refuse disclosures, subject to certain
exceptions.
KY
You may be able to restrict certain electronic
disclosures of health information.
NV
We are not allowed to use health information for
certain purposes.
CA
We will not use and/or disclose information
regarding certain public assistance programs
except for certain purposes.
MO, NJ, SD
Prescriptions
We are allowed to disclose prescription-related
ID, NH, NV
XVIII
Communicable Diseases
We are allowed to disclose communicable
disease information only (1) under certain limited
AZ, IN, KS, MI, NV, OK
Sexually Transmitted Diseases and Reproductive Health
CA, FL, HI, IN, KS, MI, MT, NJ, NV, PR, WA,
WY
We are allowed to disclose sexually transmitted
disease and/or reproductive health information
only (1) under certain limited circumstances
and/or (2) to specific recipients.
Alcohol and Drug Abuse
We are allowed to use and disclose alcohol and
drug abuse information (1) under certain limited
circumstances, and/or disclose only (2) to specific
recipients.
CT, GA, HI, KY, IL, IN, IA, LA, NC, NH, WA, WI
Disclosures of alcohol and drug abuse information
may be restricted by the individual who is the
subject of the information.
WA
Genetic Information
We are not allowed to disclose genetic information
without your written consent.
CA, CO, HI, IL, KS, KY, LA, NY, RI, TN, WY
We are allowed to disclose genetic information
AK, AZ, FL, GA, IA, MD, MA, MO, NJ, NV, NH,
NM, OR, RI, TX, UT, VT
Restrictions apply to (1) the use, and/or (2) the
retention of genetic information.
FL, GA, IA, LA, MD, NM, OH, UT, VA, VT
HIV / AIDS
We are allowed to disclose HIV/AIDS-related
circumstances and/or (2) to specific recipients.
AZ, AR, CA, CT, DE, FL, GA, HI, IA, IL, IN, KS,
KY, ME, MI, MO, MT, NY, NC, NH, NM, NV,
OR, PA, PR, RI, TX, VT, WA, WI, WV, WY
Certain restrictions apply to oral disclosures of
HIV/AIDS-related information.
CT, FL
Mental Health
We are allowed to disclose mental health
CA, CT, DC, HI, IA, IL, IN, KY, MA, MI, NC, NM,
PR, TN, WA, WI
Disclosures may be restricted by the individual
who is the subject of the information.
WA
mental health information.
CT
Certain restrictions apply to the use of mental
health information.
ME
XIX
Child or Adult Abuse
We are allowed to use and disclose child and/or
adult abuse information only (1) under certain
limited circumstances, and/or disclose only (2) to
specific recipients.
AL, CO, IL, LA, NE, NJ, NM, RI, TN, TX, UT, WI
XX
(ERISA) Rights
As a participant in the plan, you are entitled to certain rights and protections under the Employee
Retirement Income Security Act of 1974 (ERISA).
Receive Information about Your Plan and Benefits
You are entitled to examine, without charge, at the Plan Administrator's office and at other specified
locations, such as worksites and union halls, all documents governing the plan, including insurance
contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500
Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room
of the Employee Benefits Security Administration.
You are entitled to obtain, upon written request to the Plan Administrator, copies of documents governing
the operation of the plan, including insurance contracts and collective bargaining agreements, and copies
of the latest annual report (Form 5500 Series) and updated Summary Plan Description. The Plan
Administrator may make a reasonable charge for the copies.
You are entitled to continue health care coverage for yourself, spouse or Dependents if there is a loss of
coverage under the plan as a result of a qualifying event. You or your Dependents may have to pay for
such coverage. The Plan Sponsor is responsible for providing you notice of your COBRA continuation
rights. Review the Summary Plan Description and the documents governing the plan on the rules
governing your COBRA continuation coverage rights.
You are entitled to a reduction or elimination of exclusionary periods of coverage for preexisting
conditions under your group health plan, if you have creditable coverage from another group health plan.
You should be provided a certificate of creditable coverage, in writing, free of charge, from your group
health plan or health insurance issuer when you lose coverage under the plan, when you become entitled
to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request
it before losing coverage, or if you request it up to 24 months after losing coverage. You may request a
certificate of creditable coverage by calling the number on the back of your ID card. Without evidence of
creditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18 months
for late enrollees) after your enrollment date in your coverage.
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are
responsible for the operation of the employee benefit plan. The people who operate your plan, called
"fiduciaries" of the plan, have a duty to do so prudently and in the interest of you and other plan
participants and beneficiaries. No one, including your employer, your union, or any other person may fire
you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or
exercising your rights under ERISA.
Enforce Your Rights
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why
this was done, to obtain copies of documents relating to the decision without charge, and to appeal any
denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above
rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and
do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may
require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the
XXI
materials, unless the materials were not sent because of reasons beyond the control of the Plan
Administrator. If you have a claim for Benefits which is denied or ignored, in whole or in part, you may file
suit in a state or Federal court. In addition, if you disagree with the plan's decision or lack thereof
concerning the qualified status of a domestic relations order or a medical child support order, you may file
suit in Federal court. If it should happen that plan fiduciaries misuse the plan's money, or if you are
discriminated against for asserting your rights, you may seek assistance from the U.S. Department of
Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal
fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If
you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is
frivolous.
If you have any questions about your plan, you should contact the Plan Administrator. If you have any
questions about this statement or about your rights under ERISA, or if you need assistance in obtaining
documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits
Security Administration, U. S. Department of Labor listed in your telephone directory or the Division of
Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of
Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210. You may also obtain certain publications
about your rights and responsibilities under ERISA by calling the publication hotline of the Employee
Benefits Security Administration.
XXII
ERISA Statement
If the Enrolling Group is subject to ERISA, the following information applies to you.
Summary Plan Description
Name of Plan: Tekmark Global Solutions Employee Benefit Plan
Name, Address and Telephone Number of Plan Sponsor and Named Fiduciary:
100 Metroplex Drive
Edison, NJ 08817
(732) 572-9600
The Plan Sponsor retains all fiduciary responsibilities with respect to the Plan except to the extent the
Plan Sponsor has delegated or allocated to other persons or entities one or more fiduciary responsibility
with respect to the Plan.
Claims Fiduciary:
Employer Identification Number (EIN): 22-3532457
IRS Plan Number: 501
Effective Date of Plan: The effective date of the Plan is April 1, 2006; the effective date of this
restatement of the Plan is April 1, 2013
Type of Plan: Health care coverage plan
Name, business address, and business telephone number of Plan Administrator:
100 Metroplex Drive
Edison, NJ 08817
(732) 572-9600
Type of Administration of the Plan:
Benefits are paid pursuant to the terms of a group health policy issued and insured by:
185 Asylum Street
Hartford, CT 06103-3408
The Plan is administered on behalf of the Plan Administrator by UnitedHealthcare Insurance Company
pursuant to the terms of the group Policy. UnitedHealthcare Insurance Company provides administrative
services for the Plan including claims processing, claims payment, and handling appeals.
Person designated as agent for service of legal process: Plan Administrator
Source of contributions and funding under the Plan: There are no contributions to the Plan. Any
required employee contributions are used to partially reimburse the Plan Sponsor for Premiums under the
Plan. Benefits under the Plan are funded by the payment of Premium required by the group Policy.
Method of calculating the amount of contribution: Employee-required contributions to the Plan
Sponsor are the employee's share of costs as determined by Plan Sponsor. From time to time, the Plan
XXIII
Sponsor will determine the required employee contributions for reimbursement to the Plan Sponsor and
distribute a schedule of such required contributions to employees.
Date of the end of the year for purposes of maintaining Plan's fiscal records:
Plan year shall be a 12 month period ending April 1.
Determinations of Qualified Medical Child Support Orders: The plan's procedures for handling
qualified medical child support orders are available without charge upon request to the Plan
Administrator.
XXIV
For
the Health Savings Account (HSA) Plan NR4
of
Enrolling Group Number: 709590
Effective Date: April 1, 2013
Offered and Underwritten by
Table of Contents
Schedule of Benefits ...................................................................................1
Accessing Benefits............................................................................................................................... 1
Prior Authorization ............................................................................................................................... 1
Covered Health Services which Require Prior Authorization ................................................................. 2
Care Management ............................................................................................................................... 3
Special Note Regarding Medicare........................................................................................................ 3
Benefits ............................................................................................................................................... 4
Eligible Expenses .............................................................................................................................. 24
Provider Network ............................................................................................................................... 25
Continuation of Treatment when a Physician Leaves the Network ...................................................... 25
Designated Facilities and Other Providers.......................................................................................... 26
Health Services from Non-Network Providers Paid as Network Benefits ............................................. 26
Limitations on Selection of Providers.................................................................................................. 26
Certificate of Coverage ...............................................................................1
Certificate of Coverage is Part of Policy ............................................................................................... 1
Changes to the Document.................................................................................................................... 1
Other Information You Should Have..................................................................................................... 1
Introduction to Your Certificate .................................................................2
How to Use this Document................................................................................................................... 2
Information about Defined Terms ......................................................................................................... 2
Don't Hesitate to Contact Us ................................................................................................................ 2
Your Responsibilities ..................................................................................3
Be Enrolled and Pay Required Contributions........................................................................................ 3
Be Aware this Benefit Plan Does Not Pay for All Health Services ......................................................... 3
Decide What Services You Should Receive ......................................................................................... 3
Choose Your Physician........................................................................................................................ 3
Obtain Prior Authorization .................................................................................................................... 3
Pay Your Share ................................................................................................................................... 3
Pay the Cost of Excluded Services....................................................................................................... 4
Show Your ID Card .............................................................................................................................. 4
File Claims with Complete and Accurate Information ............................................................................ 4
Use Your Prior Health Care Coverage.................................................................................................. 4
Our Responsibilities....................................................................................5
Determine Benefits .............................................................................................................................. 5
Pay for Our Portion of the Cost of Covered Health Services ................................................................. 5
Pay Network Providers......................................................................................................................... 5
Pay for Covered Health Services Provided by Non-Network Providers ................................................. 5
Review and Determine Benefits in Accordance with our Reimbursement Policies................................. 5
Offer Health Education Services to You ............................................................................................... 6
Certificate of Coverage Table of Contents ...............................................7
Benefits for Covered Health Services................................................................................................... 8
1. Ambulance Services ........................................................................................................................ 8
2. Autism Spectrum Disorder and Other Developmental Disabilities – Rehabilitative Services .............. 9
3. Clinical Trials ................................................................................................................................... 9
4. Congenital Heart Disease Surgeries............................................................................................... 10
5. Dental Services - Accident Only ..................................................................................................... 11
6. Dental Services - Other.................................................................................................................. 11
7. Diabetes Services .......................................................................................................................... 12
8. Durable Medical Equipment ........................................................................................................... 13
i
9. Emergency Health Services - Outpatient ........................................................................................ 14
10. Hearing Aids ................................................................................................................................ 14
11. Hearing Loss Screening ............................................................................................................... 14
12. Hemophilia Services .................................................................................................................... 14
13. Home Health Care ....................................................................................................................... 14
14. Hospice Care ............................................................................................................................... 15
15. Hospital - Inpatient Stay ............................................................................................................... 15
16. Infertility Services......................................................................................................................... 16
17. Lab, X-Ray and Diagnostics - Outpatient ...................................................................................... 17
18. Lab, X-Ray & Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient 17
19. Medical Foods.............................................................................................................................. 17
20. Mental Health Services ................................................................................................................ 17
21. Neurobiological Disorders - Autism Spectrum Disorder Services .................................................. 18
22. New Jersey Early Intervention Family Cost Share Expense .......................................................... 19
23. Ostomy Supplies.......................................................................................................................... 19
24. Pharmaceutical Products - Outpatient .......................................................................................... 20
25. Physician Fees for Surgical and Medical Services ........................................................................ 20
26. Physician's Office Services - Sickness and Injury ......................................................................... 21
27. Pregnancy - Maternity Services.................................................................................................... 21
28. Preventive Care Services............................................................................................................. 21
29. Prosthetic and Orthotic Devices ................................................................................................... 23
30. Reconstructive Procedures .......................................................................................................... 23
31. Rehabilitation Services - Outpatient Therapy and Manipulative Treatment .................................... 24
32. Scopic Procedures - Outpatient Diagnostic and Therapeutic......................................................... 24
33. Skilled Nursing Facility/Inpatient Rehabilitation Facility Services................................................... 25
34. Specialized Non-Standard Infant Formulas................................................................................... 25
35. Substance Use Disorder Services ................................................................................................ 26
36. Surgery - Outpatient..................................................................................................................... 27
37. Therapeutic Treatments - Outpatient ............................................................................................ 27
38. Transplantation Services.............................................................................................................. 27
39. Urgent Care Center Services........................................................................................................ 28
40. Vision Examinations..................................................................................................................... 28
How We Use Headings in this Section ............................................................................................... 29
We do not Pay Benefits for Exclusions ............................................................................................... 29
Benefit Limitations.............................................................................................................................. 29
A. Alternative Treatments................................................................................................................... 29
B. Dental............................................................................................................................................ 29
C. Devices, Appliances and Prosthetics ............................................................................................. 30
D. Drugs ............................................................................................................................................ 31
E. Experimental or Investigational or Unproven Services.................................................................... 31
F. Foot Care ...................................................................................................................................... 31
G. Medical Supplies ........................................................................................................................... 32
H. Mental Health ................................................................................................................................ 32
I. Neurobiological Disorders - Autism Spectrum Disorders.................................................................. 33
J. Nutrition ......................................................................................................................................... 34
K. Personal Care, Comfort or Convenience........................................................................................ 34
L. Physical Appearance ..................................................................................................................... 35
M. Procedures and Treatments .......................................................................................................... 36
N. Providers....................................................................................................................................... 37
O. Reproduction................................................................................................................................. 37
P. Services Provided under another Plan ........................................................................................... 37
Q. Substance Use Disorders.............................................................................................................. 38
R. Transplants ................................................................................................................................... 38
S. Travel ............................................................................................................................................ 39
ii
T. Types of Care ................................................................................................................................ 39
U. Vision and Hearing ........................................................................................................................ 39
V. All Other Exclusions....................................................................................................................... 40
How to Enroll ..................................................................................................................................... 42
If You Are Hospitalized When Your Coverage Begins......................................................................... 42
Who is Eligible for Coverage .............................................................................................................. 42
Eligible Person................................................................................................................................... 42
Dependent ......................................................................................................................................... 42
When to Enroll and When Coverage Begins....................................................................................... 43
Initial Enrollment Period ..................................................................................................................... 43
Open Enrollment Period..................................................................................................................... 43
Dependent Child Special Open Enrollment Period.............................................................................. 43
New Eligible Persons ......................................................................................................................... 43
Adding New Dependents ................................................................................................................... 43
Special Enrollment Period.................................................................................................................. 44
General Information about When Coverage Ends............................................................................... 46
Events Ending Your Coverage ........................................................................................................... 46
Other Events Ending Your Coverage.................................................................................................. 47
Coverage for a Disabled Dependent Child.......................................................................................... 47
Extended Coverage for Total Disability............................................................................................... 47
Continuation of Coverage and Conversion ......................................................................................... 48
Continuation Coverage under Federal Law (COBRA)......................................................................... 48
Qualifying Events for Continuation Coverage under Federal Law (COBRA)........................................ 48
Notification Requirements and Election Period for Continuation Coverage under Federal Law (COBRA)
.......................................................................................................................................................... 49
Terminating Events for Continuation Coverage under Federal Law (COBRA)..................................... 49
New Jersey Continuation Rights for Over-Age Dependents (NJCROD) .............................................. 50
State Continuation of Coverage for Totally Disabled Subscribers ....................................................... 53
Optional State Continuation of Coverage After the Subscriber's Death ............................................... 53
Conversion ........................................................................................................................................ 53
If You Receive Covered Health Services from a Network Provider...................................................... 55
If You Receive Covered Health Services from a Non-Network Provider .............................................. 55
Required Information ......................................................................................................................... 55
Payment of Benefits........................................................................................................................... 56
What to Do if You Have a Question.................................................................................................... 57
What to Do if You Have a Complaint .................................................................................................. 57
How to Appeal a Claim Decision ........................................................................................................ 57
Post-service Claims ........................................................................................................................... 57
Pre-service Requests for Benefits ...................................................................................................... 58
How to Request an Appeal................................................................................................................. 58
Appeal Process.................................................................................................................................. 58
Appeals Determinations ..................................................................................................................... 58
Pre-service Requests for Benefits and Post-service Claim Appeals .................................................... 58
Urgent Appeals that Require Immediate Action .................................................................................. 59
External Review Program................................................................................................................... 59
Benefits When You Have Coverage under More than One Plan ......................................................... 60
When Coordination of Benefits Applies .............................................................................................. 60
Definitions.......................................................................................................................................... 60
Primary and Secondary Plan.............................................................................................................. 61
iii
Order of Benefit Determination Rules................................................................................................. 62
Effect on the Benefits of This Plan...................................................................................................... 63
Your Relationship with Us .................................................................................................................. 65
Our Relationship with Providers and Enrolling Groups........................................................................ 65
Your Relationship with Providers and Enrolling Groups ...................................................................... 66
Notice ................................................................................................................................................ 66
Statements by Enrolling Group or Subscriber ..................................................................................... 66
Incentives to Providers....................................................................................................................... 66
Incentives to You ............................................................................................................................... 67
Rebates and Other Payments ............................................................................................................ 67
Interpretation of Benefits .................................................................................................................... 67
Administrative Services...................................................................................................................... 67
Amendments to the Policy.................................................................................................................. 68
Information and Records.................................................................................................................... 68
Examination of Covered Persons ....................................................................................................... 69
Workers' Compensation not Affected ................................................................................................. 69
Refund of Overpayments ................................................................................................................... 69
Limitation of Action............................................................................................................................. 69
Entire Policy....................................................................................................................................... 70
Amendments, Riders and Notices (As Applicable)
Health Resources and Services Administration (HRSA) Amendment
Act (PPACA)
Protection Act
Amendments
(ERISA) Rights
ERISA Statement
iv
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. Emergency Health Services are always paid as Network Benefits. 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. Network Benefits 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.
because the amount paid for Eligible Expenses may be a lesser amount.
You must show your identification card (ID card) or have your provider verify your eligibility by calling us
every time you request health care services from a Network provider. If you do not show your ID card or
have your provider verify your eligibility, 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. If you have not received your ID card from us, or if you have lost your ID card, please contact us
as soon as possible. If you need to seek services and do not have your ID card, please direct your
provider to verify your eligibility by calling us to ensure proper payment of claims.
Additional information about the network of providers and how your Benefits may be affected
appears at the end of this Schedule of Benefits.
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 prior authorization is required are identified below and in the Schedule of Benefits table within each
Covered Health Service category.
We recommend that you confirm with us that all Covered Health Services listed below have been prior
authorized as required. Before receiving these services from a Network provider, you may want to contact
us to verify that the Hospital, Physician and other providers are Network providers and that they have
SBN.CHP.I.11.NJ.R2
1
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.
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. Refer to the applicable Benefit description in
the Schedule of Benefits table to determine how far in advance you must obtain prior
authorization.

Ambulance - non-emergent air and ground.

Autism Spectrum Disorder and Other Developmental Disabilities - Rehabilitative Services.

Clinical trials.

Congenital heart disease surgery.

Dental services - accidental (for follow-up (post-Emergency) treatment).

Dental services - Other (for follow-up (post-Emergency) treatment).

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).

Genetic Testing, including BRCA Genetic Testing.

Hemophilia Services.

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.

Infertility services.

Medical Foods.

Mental Health Services - inpatient services (including Partial Hospitalization/Day Treatment and
services at a Residential Treatment Facility); Intensive Outpatient Treatment programs; outpatient
SBN.CHP.I.11.NJ.R2
2
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).

Reconstructive procedures, including breast reconstruction surgery following mastectomy.

Rehabilitation services and Manipulative Treatment - Manipulative Treatment.

Skilled Nursing Facility and Inpatient Rehabilitation Facility services.

Specialized Non-Standard Infant Formulas.

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: pain management procedures, diagnostic
catheterization and electrophysiology implant and sleep apnea surgeries.

Therapeutics - only for the following services: dialysis, intensity modulated radiation therapy and
MR-guided focused ultrasound.

Transplants.
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.
Special Note Regarding Medicare
If you are enrolled in Medicare on a primary basis (Medicare pays before we pay Benefits under the
Policy), the prior authorization requirements do not apply to you. Since Medicare is the primary payer, we
will pay as secondary payer as described in Section 7: Coordination of Benefits. You are not required to
obtain authorization before receiving Covered Health Services.
SBN.CHP.I.11.NJ.R2
3
Benefits
Annual Deductibles are calculated on a Policy year basis.
Out-of-Pocket Maximums are calculated on a Policy year basis.
When Benefit limits apply, the limit stated refers to any combination of Network Benefits and Non-Network
Benefits unless otherwise specifically stated.
Benefit limits are calculated on a Policy year basis unless otherwise specifically stated.
Amounts
Annual Deductible
The amount of Eligible Expenses you pay for Covered Health
Services per year before you are eligible to receive Benefits.
The Annual Deductible applies to Covered Health Services
under the Policy as indicated in this Schedule of Benefits,
including Covered Health Services provided under the
Outpatient Prescription Drug Rider. The Annual Deductible for
Network Benefits includes the amount you pay for both
Network and Non-Network Benefits for outpatient prescription
drugs provided under the Outpatient Prescription Drug Rider.
When a Covered Person was previously covered under a
group policy that was replaced by the group Policy, any
amount already applied to that annual deductible provision of
the prior policy will apply to the Annual Deductible provision
under the Policy.
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. Details about the way in which Eligible Expenses
are determined appear at the end of the Schedule of Benefits
table.
The Annual Deductible does not apply to services provided by
capitated providers or to Non-Network lead poisoning
screenings for children.
Network
For single coverage, the Annual
Deductible is $2,500 per Covered
Person.
If more than one person in a family is
covered under the Policy, the single
coverage Annual Deductible stated
above does not apply. For family
coverage, the family Annual
Deductible is $5,000. No one in the
family is eligible to receive Benefits
until the family Annual Deductible is
satisfied.
Non-Network
For single coverage, the Annual
Deductible is $5,000 per Covered
Person.
coverage Annual Deductible stated
above does not apply. For family
coverage, the family Annual
Deductible is $10,000. No one in the
family is eligible to receive Benefits
until the family Annual Deductible is
satisfied.
Out-of-Pocket Maximum
The maximum you pay per year for the Annual Deductible,
Copayments or Coinsurance. Once you reach the Out-ofPocket Maximum, Benefits are payable at 100% of Eligible
Expenses during the rest of that year. The Out-of-Pocket
Maximum applies to Covered Health Services under the Policy
as indicated in this Schedule of Benefits, including Covered
Health Services provided under the Outpatient Prescription
Drug Rider. The Out-of-Pocket Maximum for Network Benefits
includes the amount you pay for both Network and NonSBN.CHP.I.11.NJ.R2
4
Network
For single coverage, the Out-ofPocket Maximum is $5,500 per
Covered Person.
coverage Out-of-Pocket Maximum
Amounts
Network Benefits for outpatient prescription drug products
stated above does not apply. For
family coverage, the family Out-ofPocket Maximum is $11,000.
Details about the way in which Eligible Expenses are
determined appear at the end of the Schedule of Benefits
table.
The Out-of-Pocket Maximum does not include any of the
following and, once the Out-of-Pocket Maximum has been
reached, you still will be required to pay the following:

Any charges for non-Covered Health Services.

The amount Benefits are reduced if you do not obtain
prior authorization as required.

Charges that exceed Eligible Expenses.

Copayments or Coinsurance for any Covered Health
Service identified in the Schedule of Benefits table that
does not apply to the Out-of-Pocket Maximum.
The Network Out-of-Pocket Maximum includes all Network
cost sharing, except for Copayments or Coinsurance for
Covered Health Services provided under the Outpatient
Prescription Drug Rider.
Non-Network
For single coverage, the Out-ofPocket Maximum is $9,000 per
Covered Person.
coverage Out-of-Pocket Maximum
stated above does not apply. For
family coverage, the family Out-ofPocket Maximum is $18,000.
Annual Maximum Benefit
The maximum amount we will pay for Non-Network Benefits
during the year. The Annual Maximum Benefit applies to
Covered Health Services under the Policy as indicated in this
Schedule of Benefits, including Covered Health Services
Non-Network
No Annual Maximum Benefit.
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:


50% of the Eligible Expense.
Benefits table.
Coinsurance
Coinsurance is the amount you pay (calculated as a percentage of Eligible Expenses) each time you
receive certain Covered Health Services.
SBN.CHP.I.11.NJ.R2
5
Amounts
Benefits table.
SBN.CHP.I.11.NJ.R2
6
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
In most cases, we will initiate and direct non-Emergency ambulance transportation. If you are
requesting non-Emergency ambulance services, you must obtain authorization as soon as possible
prior to transport. If you fail to obtain prior authorization as required, Benefits will be reduced to 50% of
Eligible Expenses.
Emergency Ambulance
Network
Ground Ambulance:
50%
Yes
Yes
Yes
Yes
Same as Network
Same as Network
Yes
Yes
Yes
Yes
Same as Network
Same as Network
Air Ambulance:
50%
Non-Network
Same as Network
Non-Emergency Ambulance
Network
Ground or air ambulance, as we
determine appropriate.
Ground Ambulance:
50%
Air Ambulance:
50%
Non-Network
Same as Network
2. Autism Spectrum Disorder and
Other Developmental Disabilities Rehabilitative Services
physical therapy, occupational therapy and speech therapy or as soon as is reasonably possible. If you
SBN.CHP.I.11.NJ.R2
7
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
admissions).
Inpatient:
Network
Inpatient
50%
Outpatient
Outpatient
50%


therapy.

Non-Network
Inpatient
50%
Outpatient
50%
3. Clinical Trials
You must obtain prior authorization as soon as the possibility of participation in a clinical trial arises. If
you fail to obtain prior authorization as required, Benefits will be reduced to 50% of Eligible Expenses.
Depending upon the Covered Health
Service, Benefit limits are the same
as those stated under the specific
Benefit category in this Schedule of
Benefits.
Network
Benefits.
Non-Network
SBN.CHP.I.11.NJ.R2
8
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Benefits.
4. Congenital Heart Disease
Surgeries
For Non-Network Benefits you must obtain prior authorization as soon as the possibility of a congenital
heart disease (CHD) surgery arises. If you fail to obtain prior authorization as required, Benefits will be
Network and Non-Network Benefits
under this section include only the
inpatient facility charges for the
congenital heart disease (CHD)
surgery. Depending upon where the
Covered Health Service is provided,
Benefits for diagnostic services,
cardiac catheterization and nonsurgical management of CHD will be
the same as those stated under each
Covered Health Service category in
this Schedule of Benefits.
Network
50%
Yes
Yes
Yes
Yes
Non-Network
50%
Network
50%
Yes
Yes
Same as Network
Same as Network
Non-Network
Same as Network
SBN.CHP.I.11.NJ.R2
9
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Network
Benefits.
Non-Network
Benefits.
Equipment for the management and treatment of diabetes that exceeds $1,000 in cost (either retail
purchase cost or cumulative retail rental cost of a single item). If you fail to obtain prior authorization as
Diabetes Self-Management and
Training/Diabetic Eye
Examinations/Foot Care
Network
Non-Network
Diabetes Self-Management Items
Network
Benefits for diabetes equipment that
meets the definition of Durable
Medical Equipment are not subject to
the limit stated under Durable Medical
SBN.CHP.I.11.NJ.R2
10
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Equipment.
Non-Network
Equipment that exceeds $1,000 in cost (either retail purchase cost or cumulative retail rental cost of a
single item). If you fail to obtain prior authorization as required, Benefits will be reduced to 50% of
Eligible Expenses.
Limited to $25,000 in Eligible
Expenses per year. Benefits are
limited to a single purchase of a type
of DME (including repair/replacement)
every three years. This limit does not
apply to wound vacuums.
Network
50%
Yes
Yes
Yes
Yes
Benefits for speech aid devices and
tracheo-esophageal voice devices are
limited to the purchase of one device
during the entire period of time a
Covered Person is enrolled under the
Policy. Benefits for repair/replacement
are limited to once every three years.
Speech aid and tracheo-esophageal
voice devices are included in the
annual limits stated above.
To receive Network Benefits, you
must purchase or rent the Durable
Medical Equipment from the vendor
we identify or purchase it directly from
the prescribing Network Physician.
Non-Network
50%
9. Emergency Health Services Outpatient
Note: If you are confined in a nonNetwork Hospital after you receive
SBN.CHP.I.11.NJ.R2
Network
Yes
11
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
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.
50%
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Yes
Non-Network
Same as Network
Same as Network
Same as Network
Yes
Yes
Yes
Yes
No
No
No
No
10. Hearing Aids
Limited to $2,500 per hearing aid for
each hearing impaired ear every 24
months. Accessories, fittings and
repairs are not subject to the $2,500
limit.
Network
50%
Non-Network
50%
Network
No Copayment
Non-Network
No Copayment
For Non-Network Benefits you must obtain prior authorization five business days prior to receiving
services or as soon as reasonably possible. If you fail to obtain prior authorization as required, Benefits
SBN.CHP.I.11.NJ.R2
12
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Yes
Yes
Yes
Yes
Network
50%
Non-Network
50%
services or as soon as is reasonably possible. If you fail to obtain prior authorization as required,
Benefits will be reduced to 50% of Eligible Expenses.
Limited to 60 visits per year. One visit
equals up to four hours of skilled care
services.
Network
50%
Yes
Yes
Yes
Yes
This visit limit does not include any
service which is billed only for the
administration of intravenous infusion.
Non-Network
50%
14. Hospice Care
For Non-Network Benefits you must obtain prior authorization five business days before admission for
an Inpatient Stay in a hospice facility or as soon as is reasonably possible. If you fail to obtain prior
authorization as required, Benefits will be reduced to 50% of Eligible Expenses.
In addition, for Non-Network Benefits, you must contact us within 24 hours of admission for an Inpatient
Stay in a hospice facility.
Network
50%
Yes
Yes
Yes
Yes
Non-Network
50%
days before admission, or as soon as is reasonably possible for non-scheduled admissions (including
Emergency admissions). If you fail to obtain prior authorization as required, Benefits will be reduced to
SBN.CHP.I.11.NJ.R2
13
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
50% of Eligible Expenses.
admissions).
Your cost share for Covered Health Services rendered during a hospitalization in a Network Hospital
will be limited to the Copayment, deductible and/or Coinsurance applicable to Network Services as long
as all notification requirements have been met. This applies to Covered Health Services received at a
Network Hospital regardless of whether the admitting Physician is a Network or non-Network provider.
However, although the inpatient services will be treated as Network services, the services of the nonNetwork admitting physician will be treated as non-Network services.
Network
50%
Yes
Yes
Yes
Yes
Non-Network
50%
You must obtain prior authorization as soon as possible. If you fail to obtain prior authorization as
Limited to four completed egg
retrievals per lifetime of the Covered
Person.
Network
Benefits.
Non-Network
Benefits.
17. Lab, X-Ray and Diagnostics Outpatient
Lab Testing - Outpatient:
Network
50%
Yes
Yes
Yes
Yes
Non-Network
50%
SBN.CHP.I.11.NJ.R2
14
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
X-Ray and Other Diagnostic
Testing - Outpatient:
Network
50%
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Non-Network
50%
18. Lab, X-Ray and Major
Diagnostics - CT, PET, MRI, MRA
and Nuclear Medicine - Outpatient
Network
50%
Non-Network
50%
19. Medical Foods
For Non-Network Benefits, you must obtain prior authorization as soon as possible. If you fail to obtain
Network
50%
Yes
Yes
Yes
Yes
Non-Network
50%
For Non-Network Benefits for a scheduled admission for Mental Health Services (including an
admission for Partial Hospitalization/Day Treatment and services at a Residential Treatment Facility)
you must obtain authorization prior to the admission or as soon as is reasonably possible for nonscheduled admissions (including Emergency admissions).
outpatient electro-convulsive treatment; psychological testing; extended outpatient treatment visits
beyond 45 - 50 minutes in duration, with or without medication management.
Expenses.
Network
SBN.CHP.I.11.NJ.R2
15
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Inpatient
50%
Outpatient
50%
Non-Network
Inpatient
50%
Outpatient
50%
21. Neurobiological Disorders Autism Spectrum Disorder
Services
For Non-Network Benefits for a scheduled admission for Neurobiological Disorders - Autism Spectrum
Disorder Services (including an admission for Partial Hospitalization/Day Treatment and services at a
Residential Treatment Facility) you must obtain authorization prior to the admission or as soon as is
reasonably possible for non-scheduled admissions (including Emergency admissions).
psychological testing; extended outpatient treatment visits beyond 45-50 minutes in duration, with or
without medication management; Applied Behavioral Analysis.
Expenses.
Network
Inpatient
50%
Yes
Yes
Yes
Yes
Yes
Yes
Outpatient
50%
Non-Network
Inpatient
50%
Outpatient
SBN.CHP.I.11.NJ.R2
16
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
50%
Yes
Yes
50%
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
22. New Jersey Early Intervention
Family Cost Share Expense
The Annual Deductible, Coinsurance
or Copayment as applicable to a nonSpecialist Physician visit for treatment
of a Sickness or Injury will apply to
the monthly Family Cost Share
expense.
23. Ostomy Supplies
Limited to $2,500 per year.
Network
50%
Non-Network
50%
24. Pharmaceutical Products Outpatient
Network
50%
Non-Network
50%
25. Physician Fees for Surgical and
Medical Services
Network
50%
Covered Health Services provided by
a non-Network consulting Physician,
assistant surgeon or a surgical
assistant in a Network facility will be
paid as Network Benefits. In order to
obtain the highest level of Benefits,
you should confirm the Network
status of these providers prior to
SBN.CHP.I.11.NJ.R2
Non-Network
50%
17
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
obtaining Covered Health Services.
26. Physician's Office Services Sickness and Injury
For Non-Network Benefits you must obtain prior authorization as soon as reasonably possible before
Genetic Testing, including BRCA Genetic Testing is performed. If you fail to obtain prior authorization
Network
50%
Yes
Yes
Yes
Yes
Non-Network
50%
For Non-Network Benefits you must obtain prior authorization as soon as reasonably possible if the
Inpatient Stay for the mother and/or the newborn will be more than 48 hours for the mother and
newborn child following a normal vaginal delivery, or more than 96 hours for the mother and newborn
child following a cesarean section delivery. If you fail to obtain prior authorization as required, Benefits
It is important that you notify us regarding your Pregnancy. Your notification will open the
opportunity to become enrolled in prenatal programs that are designed to achieve the best
outcomes for you and your baby.
Network
Non-Network
SBN.CHP.I.11.NJ.R2
18
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Physician office services
Network
100%
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
No
No
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Non-Network
50%
Lab, X-ray or other preventive tests
Network
Please note the Annual Deductible
does not apply to Non-Network lead
poisoning screenings for children.
100%
Non-Network
50%
Please note: Reimbursement for
these items will be at the same rate
as under the federal Medicare
reimbursement schedule.
Network
50%
Non-Network
50%
For Non-Network Benefits you must obtain prior authorization five business days before a scheduled
reconstructive procedure is performed or, for non-scheduled procedures, within one business day or as
soon as is reasonably possible. If you fail to obtain prior authorization as required, Benefits will be
inpatient admissions or as soon as is reasonably possible for non-scheduled inpatient admissions
(including Emergency admissions).
Network
Benefits.
Non-Network
SBN.CHP.I.11.NJ.R2
19
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Benefits.
31. Rehabilitation Services Outpatient Therapy and
Manipulative Treatment
Manipulative Treatment or as soon as is reasonably possible. If you fail to obtain prior authorization as
Network

50%

therapy.

20 Manipulative Treatments.


20 visits of pulmonary

36 visits of cardiac

30 visits of post-cochlear
implant aural therapy.

20 visits of cognitive
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Non-Network
50%
32. Scopic Procedures - Outpatient
Diagnostic and Therapeutic
Network
50%
Non-Network
50%
SBN.CHP.I.11.NJ.R2
20
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
33. Skilled Nursing
Facility/Inpatient Rehabilitation
Facility Services
admissions).
Network
50%
Yes
Yes
Yes
Yes
Non-Network
50%
34. Specialized Non-Standard
Infant Formulas
For Non-Network Benefits, you must obtain prior authorization at least 5 business days before
purchasing the formula, or as soon as is reasonably possible.
Network
50%
Yes
Yes
Yes
Yes
Non-Network
50%
35. Substance Use Disorder
Services
For Non-Network Benefits for a scheduled admission for Substance Use Disorder Services (including
an admission for Partial Hospitalization/Day Treatment and services at a Residential Treatment
Facility) you must obtain authorization prior to the admission or as soon as is reasonably possible for
non-scheduled admissions (including Emergency admissions).
psychological testing; extended outpatient treatment visits beyond 45 - 50 minutes in duration, with or
without medication management.
SBN.CHP.I.11.NJ.R2
21
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
Expenses.
Network
Inpatient
50%
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Outpatient
50%
Non-Network
Inpatient
50%
Outpatient
50%
For Non-Network Benefits for pain management procedures, diagnostic catheterization and
electrophysiology implant and sleep apnea surgery you must obtain prior authorization five business
days before scheduled services are received or, for non-scheduled services, within one business day
or as soon as is reasonably possible. If you fail to obtain prior authorization as required, Benefits will be
Network
50%
Yes
Yes
Yes
Yes
Non-Network
50%
37. Therapeutic Treatments Outpatient
For Non-Network Benefits you must obtain prior authorization for the following outpatient therapeutic
services five business days before scheduled services are received or, for non-scheduled services,
within one business day or as soon as is reasonably possible. Services that require prior authorization:
dialysis, intensity modulated radiation therapy and MR-guided focused ultrasound. If you fail to obtain
Network
SBN.CHP.I.11.NJ.R2
22
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
Must You Meet
Annual
Deductible?
50%
Yes
Yes
Yes
Yes
Non-Network
50%
For Network Benefits you must obtain prior authorization as soon as the possibility of a transplant
don't obtain prior authorization and if, as a result, the services are not performed at a Designated
Facility, Network Benefits will not be paid. Non-Network Benefits will apply.
For Non-Network Benefits you must obtain prior authorization as soon as the possibility of a transplant
admissions).
Network
For Network Benefits, transplantation
services must be received at a
Designated Facility. We do not
provided,
Benefits will be the same as those stated under
require that cornea transplants be
each
Covered
Health Service category in this Schedule of
performed at a Designated Facility in
Benefits.
order for you to receive Network
Benefits.
Non-Network Benefits are limited to
$200,000 per transplant. This limit
does not apply to autologous bone
marrow transplants or peripheral
blood stem cell transplants.
Non-Network
Benefits.
Network
50%
Yes
Yes
Yes
Yes
Non-Network
50%
Limited to 1 exam every 2 years.
Network
Yes
SBN.CHP.I.11.NJ.R2
23
Benefit
(The Amount We
Pay, based on
Eligible Expenses)
Apply to the
Out-of-Pocket
Maximum?
50%
Must You Meet
Annual
Deductible?
Yes
Non-Network
50%
Yes
Yes
Eligible Expenses
Eligible Expenses are the amount we determine that we will pay for Benefits. For Network Benefits, 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 non-Network providers as arranged by us,
Eligible Expenses are the fee(s) that we negotiate with the non-Network provider.

When Covered Health Services are received from a non-Network provider as a result of an
Emergency, Eligible Expenses are the provider's usual, customary and reasonable charges which
are, in our judgment, representative of the average and prevailing charge for the same health
service in the same or similar geographic communities where the health service is rendered.
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 150% 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.
♦
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:

SBN.CHP.I.11.NJ.R2
For services other than Pharmaceutical Products, we use a gap methodology
that uses a relative value scale, which is usually based on the difficulty, time,
work, risk and resources of the service. The relative value scale currently used
is created by Ingenix, Inc. If the Ingenix, Inc. relative value scale becomes no
longer available, a comparable scale will be used. We and Ingenix, Inc. are
related companies through common ownership by UnitedHealth Group.
24

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, or the provider does not submit sufficient information on the claim
to pay it under CMS published rates or a gap methodology, the Eligible Expense is
based on 50% of the provider's billed charge, except that certain Eligible Expenses for
Mental Health Services and Substance Use Disorder Services are based on 80% of
the billed charge.
♦
For Mental Health Services and Substance Use Disorder Services the Eligible
Expense will be reduced by 25% for Covered Health Services provided by a
psychologist and by 35% for Covered Health Services provided by a masters level
counselor.
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.

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.
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.
Not all Network Hospitals are contracted to perform transplants. Please refer to your provider directory or
contact us to find out which hospitals are contracted for this service.
Continuation of Treatment when a Physician Leaves the Network
If a Covered Person is receiving post-operative follow-up care, oncological treatment, psychiatric
treatment or obstetrical care by a Physician who was a Network Physician at the time the treatment was
initiated, the Covered Person may continue to be treated by that Physician for the duration of the
SBN.CHP.I.11.NJ.R2
25
treatment even if the Physician leaves the Network. The continued treatment is subject to the following
time periods:

Up to six months for post-operative follow-up care.

Up to one year for oncological treatment and psychiatric treatment.

Through the duration of a pregnancy and up to six weeks after delivery for obstetrical care.

Up to four months for other Health Services where it is medically necessary for the Covered Person
to continue treatment with that Physician.

Health Services for the continued treatment are covered as Network Benefits. Reimbursement for
Health Services will be made according to the same fee schedule used for Network Services.

During the time a Covered Person receives continued treatment by a Physician who has left the
Network, we will provide Network Benefits for any treatment or services provided to the Covered
Person in a Hospital, regardless of whether the Hospital is a Network Hospital.
Designated Facilities and Other Providers
For Transplants, we may direct you to a Designated Facility chosen by us. If you require certain complex
Covered Health Services for which expertise is limited, we may direct you to a Network facility or provider
that is outside your local geographic area. If you reside more than 50 miles from the Designated Facility
and are required to travel to obtain such Covered Health Services from the Designated Facility, we will
provide for reimbursement of travel and lodging expenses for the Covered Person and one companion.
Coverage is limited to $50/$100 lodging per day, up to a maximum Benefit of $10,000 per lifetime.
In both cases, Network Benefits will only be paid if your Covered Health Services for that condition are
provided by or arranged by the Designated Facility or other provider chosen by us.
You or your Network Physician must notify us of special service needs that might warrant referral to a
Designated Facility. If you do not notify us in advance, and if you receive services from a non-Network
facility (regardless of whether it is a Designated Facility) or other non-Network provider, Network Benefits
will not be paid. Non-Network Benefits may be available if the special needs services you receive are
Covered Health Services for which Benefits are provided under the Policy.
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.
SBN.CHP.I.11.NJ.R2
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Certificate of Coverage is Part of Policy
This Certificate of Coverage (Certificate) is part of the Policy that is a legal document between
UnitedHealthcare Insurance Company and the Enrolling Group to provide Benefits to Covered Persons,
subject to the terms, conditions, exclusions and limitations of the Policy. We issue the Policy based on the
Enrolling Group's application and payment of the required Policy Charges.
In addition to this Certificate the Policy includes:

The Group Policy.



Riders.

Amendments.
You can review the Policy at the office of the Enrolling Group during regular business hours.
Changes to the Document
We may from time to time modify this Certificate by attaching legal documents called Riders and/or
Amendments that may change certain provisions of this Certificate. When that happens we will send you
a new Certificate, Rider or Amendment pages.
No one can make any changes to the 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 the Policy, as
permitted by law, without your approval.
On its effective date, this Certificate replaces and overrules any Certificate that we may have previously
issued to you. This Certificate will in turn be overruled by any Certificate we issue to you in the future.
The Policy will take effect on the date specified in the Policy. Coverage under the Policy will begin at
12:01 a.m. and end at 12:00 midnight in the time zone of the Enrolling Group's location. The Policy will
remain in effect as long as the Policy Charges are paid when they are due, subject to termination of the
Policy.
We are delivering the Policy in the State of New Jersey and the Policy is subject to the laws of New
Jersey. The Policy is then governed by ERISA unless the Enrolling Group is not an employee welfare
benefit plan as defined by ERISA.
COC.CER.I.11.NJ
1
Introduction to Your Certificate
We are pleased to provide you with this Certificate. This Certificate and the other Policy documents
describe your Benefits, as well as your rights and responsibilities, under the Policy.
How to Use this Document
We encourage you to read your Certificate and any attached Riders and/or Amendments carefully.
We especially encourage you to review the Benefit limitations of this Certificate 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 8: General Legal Provisions to better understand how
this Certificate 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 Certificate 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
Certificate and Schedule of Benefits and any attachments in a safe place for your future reference.
If there is a conflict between this Certificate and any summaries provided to you by the Enrolling Group,
this Certificate will control.
Please be aware that your Physician is not responsible for knowing or communicating your Benefits.
Information about Defined Terms
Because this Certificate is part of 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 9: Defined Terms. You can refer to Section 9: Defined Terms as you read this document
to have a clearer understanding of your Certificate.
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 9: 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 ID card. It will be our pleasure to assist you.
COC.INT.I.11.NJ
2
Your Responsibilities
Be Enrolled and Pay Required Contributions
Benefits are available to you only if you are enrolled for coverage under the Policy. Your enrollment
options, and the corresponding dates that coverage begins, are listed in Section 3: When Coverage
Begins. To be enrolled with us and receive Benefits, both of the following apply:

Your enrollment must be in accordance with the Policy issued to your Enrolling Group, including
the eligibility requirements.

You must qualify as a Subscriber or his or her Dependent as those terms are defined in Section 9:
Defined Terms.
Your Enrolling Group may require you to make certain payments to them, in order for you to remain
enrolled under the Policy and receive Benefits. If you have questions about this, contact your Enrolling
Group.
Be Aware this Benefit Plan Does Not Pay for All Health Services
Your right to Benefits is limited to Covered Health Services. The extent of this Benefit plan'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
We understand that there are many variables that influence the decisions you make regarding your care,
including the coverage available under this plan. However, final care decisions are between you and your
Physicians. Your Physicians are solely responsible for all health services that you 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 pay a Copayment 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.
COC.YRP.I.11.NJ
3
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 Benefit plan's exclusions.
Show Your ID Card
You should show your identification (ID) card or have your provider verify your eligibility by calling us
every time you request health services. If you do not show your ID card or have your provider verify your
eligibility, 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. If you have not received
your ID card from us, or if you have lost your ID card, please contact us as soon as possible. If you need
to seek services and do not have your ID card, please direct your provider to verify your eligibility by
calling us to ensure proper payment of claims.
File Claims with Complete and Accurate Information
When you receive Covered Health Services from a non-Network provider, you have the right to make an
assignment of benefits, whereby your provider may request payment from us. You may also request
payment on your own behalf at your option. Claims must be filed 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 Benefit plan for all other
Covered Health Services that are not related to the condition or disability for which you have other
coverage.
COC.YRP.I.11.NJ
4
Our Responsibilities
Determine Benefits
We make administrative decisions regarding whether this Benefit plan will pay for any portion of the cost
of a health care service you intend to receive or have received. Our decisions are for payment purposes
only. 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.
Subject to your appeal rights set forth in the Questions, Complaints and Appeals procedures section, we

Make an initial interpretation of Benefits and the other terms, limitations and exclusions set out in
this Certificate, 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 Benefit plan, such as claims processing. The identity of the service providers and the nature of their
services may be changed from time to time in our discretion. 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 Benefit plan.
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 or your
non-Network provider's 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:

(CMS).


COC.ORP.I.11.NJ
5

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
obtain copies of our reimbursement policies for yourself or to share with your non-Network Physician or
provider by going to www.myuhc.com or 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.
COC.ORP.I.11.NJ
6
Certificate of Coverage Table of Contents
COC.TOC.I.11.NJ
7
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 or medically appropriate. (See definitions of Medically Necessary and
Covered Health Service in Section 9: 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 use disorder, disease or its symptoms
does not mean that the procedure or treatment is a Covered Health Service under the Policy.

Covered Health Services are received while the Policy is in effect or during any extension of
benefits period.

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 specified in the Policy.
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 you are required to pay in a year (Out-of-Pocket Maximum).

Any responsibility you have for obtaining prior authorization or notifying us.
Emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance)
to the nearest Hospital where Emergency Health Services can be performed.
Non-Emergency ambulance transportation by a licensed ambulance service (either ground or air
ambulance, as we determine appropriate) between facilities when the transport is any of the following:

From a non-Network Hospital to a Network Hospital.

To a Hospital that provides a higher level of care that was not available at the original Hospital.

To a more cost-effective acute care facility.

From an acute facility to a sub-acute setting.
COC.CHS.I.11.NJ
8
2. Autism Spectrum Disorder and Other Developmental Disabilities –
Rehabilitative Services
For Covered Persons with a primary diagnosis of Autism Spectrum Disorder or another Developmental
Disability, Benefits under this section include:

Physical therapy provided by a licensed physical therapist.

Speech and language pathology services provided by a licensed speech and language pathologist.

Occupational therapy provided by a licensed occupational therapist.
Benefits for these therapies will be provided as prescribed through a treatment plan and will not be denied
on the basis that the treatment is not restorative.
The treatment plan must include all elements necessary to appropriately provide Benefits, including, but
not limited to:

a diagnosis;

proposed treatment by type, frequency, and duration;

the anticipated outcomes stated as goals; the frequency by which the treatment plan will be
updated;

and the treating Physician’s signature.
We may request an updated treatment plan once every six months from your Physician to review medical
necessity, unless a more frequent review is agreed upon due to emerging clinical circumstances.
Please note, Benefits for psychiatric treatment for Autism Spectrum Disorder (including evaluation and
assessment services, applied behavior analysis and behavior training and behavior management) are
described above under Neurobiological Disorders - Autism Spectrum Disorder Services.
3. Clinical Trials
Routine patient care costs incurred during participation in a qualifying clinical trial for the treatment of:

Cancer.

Cardiovascular disease (cardiac/stroke).

Surgical musculoskeletal disorders of the spine, hip and knees.

Other diseases or disorders 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 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 clinical
trial as defined by the researcher. Benefits are not available for preventive clinical trials.
Routine patient care costs for 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 Investigational item or service, the
clinically appropriate monitoring of the effects of the item or service, or the prevention of
complications.
COC.CHS.I.11.NJ
9

Covered Health Services needed for reasonable and necessary care arising from the provision of
an Investigational item or service.
Routine costs for clinical trials do not include:

The Experimental or Investigational Service 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.

Items and services provided by the research sponsors free of charge for any person enrolled in the
trial.
To be a qualifying clinical trial, a clinical trial must meet all of the following criteria:

Be sponsored and provided by a cancer center that has been designated by the National Cancer
Institute (NCI) as a Clinical Cancer Center or Comprehensive Cancer Center or be sponsored by
any of the following:

National Institutes of Health (NIH). (Includes National Cancer Institute (NCI).)

Centers for Disease Control and Prevention (CDC).

Agency for Healthcare Research and Quality (AHRQ).

Centers for Medicare and Medicaid Services (CMS).

Department of Defense (DOD).

Veterans Administration (VA).

The clinical trial must have a written protocol that describes a scientifically sound study and have
been approved by all relevant institutional review boards (IRBs) before participants are enrolled in
the trial. We may, at any time, request documentation about the trial.

The subject or purpose of the trial must be the evaluation of an item or service that meets the
definition of a Covered Health Service and is not otherwise excluded under the Policy.
4. Congenital Heart Disease Surgeries
Congenital heart disease (CHD) surgeries which are ordered by a Physician. CHD surgical procedures
include surgeries to treat conditions such as coarctation of the aorta, aortic stenosis, tetralogy of fallot,
transposition of the great vessels and hypoplastic left or right heart syndrome.
Benefits under this section include the facility charge and the charge for supplies and equipment. Benefits
for Physician services are described under Physician Fees for Surgical and Medical Services.
Surgery may be performed as open or closed surgical procedures or may be performed through
interventional cardiac catheterization.
We have specific guidelines regarding Benefits for CHD services. Contact us at the telephone number on
your ID card for information about these guidelines.
COC.CHS.I.11.NJ
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Dental services when all of the following are true:

Treatment is necessary because of accidental damage.

Dental services are received from a Doctor of Medicine, "M.D.", Doctor of Dental Surgery, "D.D.S."
or Doctor of Medical Dentistry, "D.M.D.".

The dental damage is severe enough that initial contact with a Physician or dentist occurred within
72 hours of the accident. (You may request an extension of this time period provided that you do so
within 60 days of the Injury and if extenuating circumstances exist due to the severity of the Injury.)
Please note that dental damage that occurs as a result of normal activities of daily living or extraordinary
use of the teeth is not considered having occurred as an accident. Benefits are not available for repairs to
teeth that are damaged as a result of such activities.
Dental services to repair damage caused by accidental Injury must conform to the following time-frames:

Treatment is started within three months of the accident, unless extenuating circumstances exist
(such as prolonged hospitalization or the presence of fixation wires from fracture care).

Treatment must be completed within 12 months of the accident.
Benefits for treatment of accidental Injury are limited to the following:

Emergency examination.

Necessary diagnostic X-rays.

Endodontic (root canal) treatment.

Temporary splinting of teeth.

Prefabricated post and core.

Simple minimal restorative procedures (fillings).

Extractions.

Post-traumatic crowns if such are the only clinically acceptable treatment.

Replacement of lost teeth due to the Injury by implant, dentures or bridges.
Services including surgery, general anesthesia and associated Hospital or Alternate Facility charges
when the dentist and Physician determine that the services are necessary for the safe and effective
treatment of one of the following:

A dental condition.

A medical condition covered under the Policy which requires hospitalization or general anesthesia
for dental services rendered by a Doctor of Medicine, "M.D.", Doctor of Dental Surgery, "D.D.S.", or
Doctor of Medical Dentistry "D.M.D." regardless of where the dental services are provided.
Services are limited to Covered Persons who are one of the following:

A child under 5 years of age.

A person who is severely disabled.
COC.CHS.I.11.NJ
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Services for the diagnosis or treatment of a dental disease are not Covered Health Services.
Diabetes Self-Management and Training/Diabetic Eye Examinations/Foot Care
Outpatient self-management training for the treatment of diabetes, education and medical nutrition
therapy services to ensure that a person with diabetes is educated regarding the proper self-management
and treatment of their diabetic condition, including information on proper diet. Diabetes outpatient selfmanagement training, education and medical nutrition therapy services must be ordered by a Physician
and provided by appropriately licensed or registered healthcare professionals.
Covered services for self-management and diet education are limited to the following:

Visits as Medically Necessary upon the diagnosis of diabetes.

Visits as Medically Necessary upon diagnosis by a Physician or nurse practitioner/clinical nurse
specialist of a significant change in the person's symptoms or conditions which necessitate
changes in that person's self-management.

Visits as Medically Necessary upon the determination of a Physician or nurse practitioner/clinical
nurse specialist that reeducation or refresher education is necessary.
Diabetes self-management education must be provided by one of the following:

A dietitian who is registered by a nationally-recognized professional association of dietitians.

A health care professional recognized as a certified diabetes educator by the American Association
of Diabetes Educators.

A registered pharmacist qualified regarding management education for diabetes by any institution
recognized by the Board of Pharmacy of the State of New Jersey.
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. Benefits for blood glucose monitors and blood glucose monitors for the
legally blind, insulin syringes with needles, test strips for glucose monitors and visual reading and urine
testing strips, ketone test strips and tablets, insulin, injection aids, oral agents for controlling blood sugar
and lancets and lancet devices are described under the Outpatient Prescription Drug Rider.

Blood glucose monitors and blood glucose monitors for the legally blind.

Insulin syringes with needles.

Test strips for glucose monitors and visual reading and urine testing strips.

Ketone test strips and tablets.

Insulin.

Injection aids.

Oral agents for controlling blood sugar.

Lancets and lancet devices.
COC.CHS.I.11.NJ
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The equipment and supplies must be recommended or prescribed by a Physician or nurse
practitioner/clinical nurse specialist.
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:

Mobility Devices.

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 Certificate.
Benefits under this section also include speech aid devices and tracheo-esophageal voice devices
required for treatment of severe speech impediment or lack of speech directly attributed to Sickness or
Injury. Benefits for the purchase of speech aid devices and tracheo-esophageal voice devices are
available only after completing a required three-month rental period. Benefits are limited as stated in the
Schedule of Benefits.
Benefits under this section do not include any device, appliance, pump, machine, stimulator, or monitor
that is fully implanted into the body.
We will decide if the equipment should be purchased or rented.
COC.CHS.I.11.NJ
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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.
9. 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.
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).
10. Hearing Aids
Hearing aids required for the correction of a hearing impairment (a reduction in the ability to perceive
sound which may range from slight to complete deafness). Hearing aids are electronic amplifying devices
designed to bring sound more effectively into the ear.
Benefits are available for a hearing aid that is purchased as a result of a written recommendation by a
Physician. Benefits are provided for the hearing aid and associated accessories, as well as for charges
associated with the fitting, testing and repair of a hearing aid.
Benefits under this section do not include bone anchored hearing aids. Bone anchored hearing aids are a
Covered Health Service for which Benefits are available under the applicable medical/surgical Covered
Health Services categories in this Certificate, only for Covered Persons who have either of the following:

Craniofacial anomalies whose abnormal or absent ear canals preclude the use of a wearable
hearing aid.

Hearing loss of sufficient severity that it would not be adequately remedied by a wearable hearing
aid.
Coverage for screening for newborn hearing loss by appropriate electrophysiologic screening measures
and periodic monitoring of infants for delayed onset hearing loss. No Copayment amount or Annual
Deductible applies to these Benefits.
Coverage is provided for home treatment of routine bleeding episodes due to hemophilia. The treatment
must be supervised by a state-approved hemophilia treatment center. Coverage is provided for blood
products including, but not limited to Factor VIII, Factor IX and Cryoprecipitate. Coverage is also provided
for blood infusion equipment including, but not limited to, syringes and needles.
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.
COC.CHS.I.11.NJ
14
Benefits are available when the Home Health Agency services are provided on a part-time, Intermittent
Care schedule and when skilled care is required or when continued hospitalization would otherwise be
required.
Benefits are available for full-time nursing care and full-time care by an aide on a short-term basis if
needed. Home Health Agency services include physical, occupational, or speech therapy, medical social
work and nutritional services.
Benefits are available for the following items to the extent that they would have been available if the
Covered Person were confined in a Hospital:

Medical supplies.

Drugs and medications ordered by a Physician.

Laboratory services given or ordered in a Hospital.

Special meals.

Diagnostic, therapeutic or surgical services provided on an outpatient basis at a Hospital or
Alternate Facility or in a Physician's office.
Skilled care is skilled nursing, skilled teaching, skilled rehabilitation services, and home health aide
services when all of the following are true:





It is not Custodial Care.
14. 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.
Services and supplies provided during an Inpatient Stay in a Hospital. Benefits are available for:


COC.CHS.I.11.NJ
15

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.)

48 hours following a simple mastectomy.

72 hours following a modified radical mastectomy.
If you agree, the attending provider may discharge you earlier than these minimum time frames.
Your cost share for Covered Health Services rendered during a hospitalization in a Network Hospital will
be limited to the Copayment, deductible or Coinsurance applicable to Network Services as long as all
request for pre-authorization requirements have been met. Please refer to your Schedule of Benefits for
the Copayment, deductible, Coinsurance and pre-authorization requirements that apply to your plan. This
applies to Covered Health Services received at a Network Hospital regardless of whether the admitting
Physician is a Network or non-Network provider. However, although the inpatient services will be treated
as Network services, the services of the non-Network admitting Physician will be treated as non-Network
services.
Benefits for Infertility will be paid at the same level as Benefits for any other maternity-related procedure.
Diagnosis and treatment of Infertility including but not limited to:

Diagnosis and diagnostic tests.

Medications.

Surgery.

In vitro fertilization.

Embryo transfer.

Zygote intra fallopian transfer.

Intracytoplasmic sperm injection.

Gamete intra fallopian transfer.

Four completed egg retrievals per lifetime of the Covered Person.

Medical costs of egg and sperm donors.
Benefits for gamete intra fallopian transfer, in vitro fertilization and zygote intra fallopian transfer are
limited to a Covered Person who meets all of the following conditions:

The Covered Person has used all reasonable, less expensive and medically appropriate treatments
and is still unable to become pregnant or carry a pregnancy.

The Covered Person has not reached the limit of four completed egg retrievals.

The Covered Person is 45 years of age or younger.
Services must be performed at facilities that conform to standards established by the American Society
for Reproductive Medicine or the American College of Obstetrics and Gynecologists.
COC.CHS.I.11.NJ
16
17. 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 include:

Lab and radiology/X-ray.


When these services are performed in a Physician's office, Benefits are described under Physician's
Office Services - Sickness and Injury.
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.
18. Lab, X-Ray & 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.


19. Medical Foods
Benefits for Medical Foods and Low Protein Modified Food Products when prescribed for the therapeutic
treatment of Inherited Metabolic Diseases and administered under the direction of a Physician.
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.
This section does not include services related to Autism Spectrum Disorders. Treatment for Autism
Spectrum Disorder is a Covered Health Service for which Benefits are payable as described under
Neurobiological Disorders - Autism Spectrum Disorder Services.


Treatment planning.

Referral services.


COC.CHS.I.11.NJ
17




Benefits under this section include Biologically Based Mental Illness as required by New Jersey insurance
law.
Special Mental Health Programs and Services
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 the Policy. You must be referred to such programs through the Mental
Health/Substance Use Disorder 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.
21. Neurobiological Disorders - Autism Spectrum Disorder Services
Psychiatric services 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 for Autism Spectrum
Disorders 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.
This section describes only the psychiatric component of treatment for Autism Spectrum Disorders.
Medical treatment of Autism Spectrum Disorders is a Covered Health Service for which Benefits are
available as described under Autism Spectrum Disorder and Other Developmental Disabilities –
Rehabilitative Services. Benefits include the following services provided on either an inpatient or
outpatient basis:


Treatment planning.

Referral services.

COC.CHS.I.11.NJ
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




For Covered Persons under 21 years of age, and when the primary diagnosis is autism, Benefits are
provided for Medically Necessary Behavioral Interventions Based on the Principles of Applied Behavioral
Analysis (“ABA”) and Related Structured Behavioral Programs as prescribed through a treatment plan
and provided by or under the direct supervision of an experienced individual who is credentialed by the
national Behavior Analyst Certification Board as either:

Board Certified Behavior Analyst – Doctoral (BCBA-D); or

Board Certified Behavior Analyst (BCBA).
22. New Jersey Early Intervention Family Cost Share Expense
Benefits under this section include the Family Cost Share expense incurred by Covered Persons for the
provision of certain health care services obtained in accordance with a treatment plan developed as a
result of, or in conjunction with, an Individualized Family Service Plan (IFSP) for a child determined
eligible for early intervention services through the New Jersey Early Intervention System (NJEIS).
In order to be eligible for reimbursement, the Covered Person must:
a)
be eligible for early intervention services through the New Jersey Early Intervention System;
b)
have been diagnosed with Autism Spectrum Disorder or another Developmental Disability; and
c)
received physical therapy, occupational therapy, speech therapy, applied behavior analysis or
related structured behavior services.
The portion of the Family Cost Share attributable to such services is a Covered Health Service under the
Policy. The deductible, Coinsurance or Copayment as applicable to a non-Specialist Physician visit for
treatment of a Sickness or Injury will apply to the monthly Family Cost Share expense.
The therapy services a Covered Person received through New Jersey Early Intervention do not reduce
the therapy services otherwise available under the Policy.
23. Ostomy Supplies
Benefits for ostomy supplies are limited to the following:

Pouches, face plates and belts.

Irrigation sleeves, bags and ostomy irrigation catheters.
COC.CHS.I.11.NJ
19

Skin barriers.
Benefits are not available for deodorants, filters, lubricants, tape, appliance cleaners, adhesive, adhesive
remover, or other items not listed above.
24. 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. Benefits under this section do not
include medications for the treatment of infertility.
Benefits for certain Pharmaceutical Products are subject to the supply limits that are stated in the
Schedule of Benefits. For a single Copayment and/or Coinsurance, you may receive Pharmaceutical
Products 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 order or
refill and/or the amount dispensed per month's supply.
You may determine whether a Pharmaceutical 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.
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
25. 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.
Physician fees for a second opinion, including the review of the results of any laboratory and radiology
essential to the second opinion, where another licensed Physician proposes to perform an elective
inpatient surgical procedure on a Covered Person. For purposes of this benefit, an inpatient surgical
procedure is one which is scheduled at the convenience of the Covered Person or the covered Person's
Physician without jeopardizing the Covered Person's life or causing serious impairment to the Covered
Person's bodily functions. If the second surgical opinion does not confirm that the proposed elective
surgical procedure is medically advisable, then Physician Fees for a third surgical opinion shall be
covered in the same manner as those covered for a second surgical opinion. A Physician providing a
second or third surgical opinion shall be a physician who is licensed to practice medicine and surgery who
holds the rank of Diplomate of an American Board (M.D.) or Certified Specialist (O.D.) in the surgical or
medical specialty for which surgery is proposed. In the event that the Physician who provides a second or
third surgical opinion also performs the elective surgical procedure being proposed, then no benefits for
the second or third opinion will be paid to that Physician.
COC.CHS.I.11.NJ
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26. 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:

treatment.

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 injections.
Covered Health Services for preventive care provided in a Physician's office are described under
Benefits under this section include lab, radiology/X-ray or other diagnostic services performed in the
Physician's office. Benefits under this section do not include CT scans, PET scans, MRI, MRA, nuclear
medicine and major diagnostic 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 may 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 any available
prenatal programs designed to achieve the best outcomes for you and your baby.

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.
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:

COC.CHS.I.11.NJ
21



Benefits provided include the following:

Screening and diagnostic mammography.

Screening for colorectal cancer as follows:

Annual guaiac-based fecal occult blood test (gFOBT) with high test sensitivity for cancer.

Annual immunochemical-based fecal occult blood test (FIT) with high test sensitivity for
cancer.

Stool DNA (sDNA) test with high test sensitivity for cancer.

S
 creening colonoscopy or Flexible sigmoidoscopy every five years.

Colonoscopy every ten years.

Double contract barium enema every five years.

Computed tomography colonography (virtual colonoscopy) every five years.

A Pap smear including all laboratory costs associated with the Pap smear and any confirmatory
test.

Cervical cancer screening.

Prostate cancer screening which includes an annual diagnostic examination including, but not
limited to, a digital rectal examination and a prostate-specific antigen test for men age 50 and over
who are asymptomatic and for men age 40 and over with a family history of prostate cancer or
other prostate cancer risk factors.

Screening for blood lead measurement for lead poisoning for children. Screening for blood lead
measurement includes confirmatory blood lead testing and medical evaluation and any necessary
medical follow-up and treatment of lead-poisoned children.

Bone mineral density tests.
Health Wellness Exams
Benefits are provided for health wellness examinations which include the following tests and services:

For Covered Persons 20 years of age and older, annual tests to determine blood hemoglobin,
blood pressure, blood glucose level, and blood cholesterol level or, alternatively, low-density
liporotein (LDL) level and blood high-density lipoprotein (HDL) level.

For Covered Persons 35 years of age or older, a glaucoma eye test every five years.

For Covered Persons 40 years of age or older, an annual stool examination for presence of blood.

For Covered Persons 45 years of age or older, a left-sided colon examination of 35 to 60
centimeters every five years.
COC.CHS.I.11.NJ
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
For women 20 years of age or older, a pap smear.

For women who are at least 35 but less than 40, one baseline mammogram examination.

For women 40 years of age or older, a mammogram examination.

For adult Covered Persons, recommended immunizations.

Other tests and services recommended as medically appropriate by a Physician.

For all persons 20 years of age or older, an annual consultation with a Physician to discuss lifestyle
behaviors that promote health and well-being including, but not limited to, smoking control, nutrition
and diet recommendations, exercise plans, lower back protection, weight control, immunization
practices, breast self-examination, testicular self-examination and seat belt usage in motor
vehicles.
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.
Orthotic appliances that straighten or re-shape a body part. For the purpose of this Benefit this refers to a
brace or support but does not include fabric and elastic supports, corsets, arch supports, trusses, elastic
hose, canes, crutches, cervical collars, dental appliances or other similar devices carried in stock and sold
by drug stores, department stores, corset shops or surgical supply facilities.
Benefits under this section are provided only for external prosthetic devices and do not include any device
that is fully implanted into the body other than breast prostheses.
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 who deems
the device to be Medically Necessary and must be obtained from a licensed orthotist or prosthetist, or any
certified pedorthist.
Benefits are available for repairs and replacement if deemed to be Medically Necessary by a Physician.
Reimbursement for these items will be at the same rate as under the federal Medicare reimbursement
schedule.
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 implanted 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.
COC.CHS.I.11.NJ
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Other 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.
Reconstructive procedures include the necessary care and treatment of medically diagnosed congenital
defects and birth abnormalities of newborn children. These procedures that correct an anatomical
Congenial Anomaly are not considered Cosmetic Procedures.
Cosmetic Procedures are excluded from coverage. The fact that a Covered Person may suffer
psychological consequences or socially avoidant behavior as a result of an Injury or Sickness does not
classify surgery (or other procedures done to relieve such consequences or behavior) as a reconstructive
procedure.
31. Rehabilitation Services - Outpatient Therapy and Manipulative Treatment
Short-term outpatient rehabilitation services, limited to:

Physical therapy.

Occupational therapy.

Manipulative Treatment.

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.
rehabilitation services or if rehabilitation goals have previously been met. Benefits can be denied or
shortened for Covered Persons who are not progressing in goal-directed Manipulative Treatment or if
treatment goals have previously been met. Benefits under this section are not available for
maintenance/preventive Manipulative Treatment.
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 Disorders. We will pay Benefits for cognitive
rehabilitation therapy only when Medically Necessary following a post-traumatic brain Injury or cerebral
vascular accident.
Please note that Benefits under this section do not include physical therapy, occupational therapy
or speech therapy for the diagnosis of Autism Spectrum Disorders or other Developmental
Disabilities. Benefits for these services payable as described in Autism Spectrum Disorder and
Other Developmental Disabilities - Rehabilitative Services above.
32. 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.
COC.CHS.I.11.NJ
24
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.


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
33. 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:



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:




rehabilitation services or if discharge rehabilitation goals have previously been met.
34. Specialized Non-Standard Infant Formulas
Coverage for specialized non-standard infant formulas when the following conditions are met:
COC.CHS.I.11.NJ
25

The covered infant's Physician has diagnosed the infant as having multiple food protein
intolerance.

The covered infant's Physician has determined specialized non-standard infant formulas to be

The covered infant has not been responsive to trials of standard non-cow milk-based formulas,
including soybean and goat milk.
Benefits are provided to the same extent as for other medical foods as described under the heading
Medical Foods.
35. Substance Use Disorder Services
Substance Use Disorder 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.


Treatment planning.

Referral services.






Special Substance Use Disorder Programs and Services
Designee may become available to you as a part of your Substance Use Disorder Services Benefit. The
Substance Use Disorder 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 use disorder which may not otherwise be covered under the Policy. You must be referred to
such programs through the Mental Health/Substance Use Disorder 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.
COC.CHS.I.11.NJ
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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.


37. 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:

treatment.


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.
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. Benefits are
available for the treatment of Wilms' tumor, including autologous bone marrow transplants when standard
chemotherapy is unsuccessful, even when such treatment is considered Experimental or Investigational.
Treatment of cancer by dose-intensive chemotherapy/autologous bone marrow transplants and peripheral
blood stem cell transplants are a Covered Health Service for which Benefits are payable when performed
at a Provider that is approved by the National Cancer Institute or performed pursuant to protocols
consistent with the guidelines of the American Society of Clinical Oncologists.
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 the Policy.
COC.CHS.I.11.NJ
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Transplantation services must be performed at our Designated Facilities in order to receive an in-Network
level of Benefits. Refer to the Schedule of Benefits for applicable prior authorization requirements. Please
note that not all Network Hospitals are contracted to perform transplants. Please refer to your provider
directory or contact us to find out which hospitals are contracted for this service.
If you reside more than 50 miles from the Designated Facility and are required to travel to obtain
transplantation services from the Designated Facility, we will provide for reimbursement of travel and
lodging expenses for the Covered Person and one companion. Coverage is limited to $50/$100 lodging
per day, up to a maximum Benefit of $10,000 per lifetime. We have specific guidelines regarding Benefits
for transplant services. Contact us at the telephone number on your ID card for information about these
guidelines.
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.
Routine vision examinations, including refraction to detect vision impairment, received from a health care
provider in the provider's office.
Please note that Benefits are not available for charges connected to the purchase or fitting of eyeglasses
or contact lenses.
Benefits for eye examinations required for the diagnosis and treatment of a Sickness or Injury are
provided under Physician's Office Services - Sickness and Injury.
COC.CHS.I.11.NJ
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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 the Policy.
Benefit Limitations
When Benefits are limited within any of the Covered Health Service categories described in Section 1:
Covered Health Services, those limits are stated in the corresponding Covered Health Service category in
the Schedule of Benefits. Limits may also apply to some Covered Health Services that fall under more
than one Covered Health Service category. When this occurs, those limits are also stated in the Schedule
of Benefits under the heading Benefit Limits. Please review all limits carefully, as we will not pay Benefits
for any of the services, treatments, items or supplies that exceed these Benefit limits.
A. Alternative Treatments
1.
Acupressure and acupuncture.
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 Manipulative
Treatment and non-manipulative osteopathic care for which Benefits are provided as described in
B. Dental
1.
Dental care (which includes dental X-rays, supplies and appliances and all associated expenses,
including hospitalizations and anesthesia).
COC.EXC.I.11.NJ
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This exclusion does not apply to dental care (oral examination, X-rays, extractions and non-surgical
elimination of oral infection) required for the direct treatment of a medical condition for which
Benefits are available under the 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.
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 Dental
Services - Accident Only and Dental Services - Other 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 except for treatment of medically diagnosed congenital birth defects and birth
abnormalities in Dependents that have been covered under the Certificate from the moment of
birth.
C. Devices, Appliances and Prosthetics
1.
Devices used specifically as safety items or to affect performance in sports-related activities.
2.
Cranial banding.
3.
The following items are excluded, even if prescribed by a Physician:

Blood pressure cuff/monitor.

Enuresis alarm.

Non-wearable external defibrillator.

Trusses.

Ultrasonic nebulizers.
COC.EXC.I.11.NJ
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4.
Devices and computers to assist in communication and speech except for speech aid devices and
tracheo-esophageal voice devices for which Benefits are provided as described under Durable
Medical Equipment in Section 1: Covered Health Services.
5.
Oral appliances for snoring.
6.
Repairs to prosthetic devices due to misuse, malicious damage or gross neglect.
7.
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. This
exclusion does not apply to oral agents for controlling blood sugar or to medications used to treat
infertility for which Benefits are provided as described under Diabetes Services and Infertility
2.
Self-injectable medications except as described under the heading Diabetes Services in Section 1:
Covered Health Services. 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.
3.
4.
Services.
5.
6.
7.
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 or to
the treatment for Wilm's tumor as described under Transplantation Services 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.
COC.EXC.I.11.NJ
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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.
Arch supports.
G. Medical Supplies
1.
Prescribed or non-prescribed medical supplies and disposable supplies. Examples include:

Compression stockings.

Ace bandages.

Gauze and dressings.

Urinary catheters.
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

Ostomy supplies for which Benefits are provided as described under Ostomy Supplies in
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
Exclusions listed directly below apply to services described under Mental Health Services in Section 1:
1.
2.
Mental Health Services as treatments for V-code conditions as listed within the current edition of
the Diagnostic and Statistical Manual of the American Psychiatric Association.
3.
Mental Health Services as treatment for a primary diagnosis of insomnia and other sleep disorders,
sexual dysfunction disorders, feeding disorders, neurological disorders and other disorders with a
known physical basis.
4.
COC.EXC.I.11.NJ
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5.
6.
7.
8.
Mental retardation 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 Neurobiological Disorders
- Autism Spectrum Disorder Services in Section 1: Covered Health Services.
9.
Services or supplies for the diagnosis or treatment of Mental Illness that, in the reasonable
judgment of the Mental Health/Substance Use Disorder Designee, are any of the following:

such conditions.



Not clinically appropriate for the patient's Mental Illness or condition based on Generally
Accepted Standards of Medical Practice and benchmarks.
and procedures.
I. Neurobiological Disorders - Autism Spectrum Disorders
Exclusions listed directly below apply to services described under Neurobiological 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.
3.
Mental retardation as the primary diagnosis defined in the current edition of the Diagnostic and
Statistical Manual of the American Psychiatric Association.
4.
5.
Diagnostic and Statistical Manual of the American Psychiatric Association and which are not a part
of Autism Spectrum Disorder.
6.
7.
Services or supplies for the diagnosis or treatment of Autism Spectrum Disorder that, in the
reasonable judgment of the Mental Health/Substance Use Disorder Designee, are any of the
following:
COC.EXC.I.11.NJ
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
such conditions.



Not clinically appropriate for the patient's Autism Spectrum Disorder or condition based on
and procedures.
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.
3.
Infant formula and donor breast milk except as provided under Medical Foods and Specialized
Non-Standard Infant Formulas in Section 1: Covered Health Services.
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:



Breast pumps.

Car seats.


Exercise equipment.
COC.EXC.I.11.NJ
34


Hot tubs.

Humidifiers.

Jacuzzis.

Mattresses.


Motorized beds.

Music devices.

Personal computers.

Pillows.


Radios.

Saunas.


Strollers.

Safety equipment.

Treadmills.


Video players.

Whirlpools.
L. Physical Appearance
1.
Cosmetic Procedures. See the definition in Section 9: 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.
We pay Benefits for the necessary care and treatment of medically diagnosed congenital defects
and birth abnormalities of newborn children.
COC.EXC.I.11.NJ
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2.
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:
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 regardless of the reason for the hair loss.
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.
Speech therapy except as required for treatment of a speech impediment or speech dysfunction
that results from Injury, stroke, cancer, Congenital Anomaly, or Autism Spectrum Disorders.
5.
Outpatient cognitive rehabilitation therapy except as Medically Necessary following a posttraumatic brain Injury or cerebral vascular accident.
6.
Psychosurgery.
7.
Sex transformation operations and related services.
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.
10.
Services for the evaluation and treatment of temporomandibular joint syndrome (TMJ), whether the
services are considered to be medical or dental in nature.
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:
COC.EXC.I.11.NJ
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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 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.
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.
2.
Surrogate parenting.
3.
The reversal of voluntary sterilization.
P. Services Provided under another Plan
1.
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, or similar legislation.
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.
3.
Health services for treatment of military service-related disabilities:

organization; and

Health services while on active military duty:

organization; and
COC.EXC.I.11.NJ
37

Q. Substance Use Disorders
Exclusions listed directly below apply to services described under Substance Use Disorder Services in
1.
2.
Methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol), Cyclazocine, or their
equivalents.
3.
4.
Services or supplies for the diagnosis or treatment of alcoholism or substance use disorders that, in
the reasonable judgment of the Mental Health/Substance Use Disorder Designee, are any of the
following:

such conditions.

services or supplies will have a measurable and beneficial health outcome, and therefore
considered experimental/investigational or unproven.


Not clinically appropriate for the patient's substance use disorder or condition based on
If you are dissatisfied with the decision of the Mental Health/Substance Use Disorder Designee,
you have the right to appeal. Please refer to Section 6: Questions, Complaints and Appeals for
appeals process and procedures.
R. Transplants
1.
Health services for organ and tissue transplants, except those described under Transplantation
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 the Policy.)
3.
Health services for transplants involving permanent mechanical or animal organs.
4.
cornea transplants.
5.
cornea transplants.
COC.EXC.I.11.NJ
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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 at our discretion. Refer to Transplantation Services in Section 1: Covered
Health Services for more information. This exclusion does not apply to ambulance transportation
for which Benefits are provided as described under Ambulance Services in Section 1: Covered
Health Services.
T. Types of Care
1.
Multi-disciplinary pain management programs provided on an inpatient basis for acute pain or for
exacerbation of chronic pain.
2.
Custodial Care or maintenance care regardless of whether provided in a home setting or in a
facility.
3.
Private Duty Nursing.
4.
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.
5.
Rest cures.
6.
Services of personal care attendants.
7.
Work hardening (individualized treatment programs designed to return a person to work or to
prepare a person for specific work).
U. Vision and Hearing
1.
Purchase cost and fitting charge for eyeglasses and contact lenses.
2.
Implantable lenses used only to correct a refractive error (such as Intacs corneal implants).
3.
Eye exercise or vision therapy.
4.
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.
5.
Bone anchored hearing aids except when either of the following applies:

For Covered Persons with craniofacial anomalies whose abnormal or absent ear canals
preclude the use of a wearable hearing aid.

For Covered Persons with hearing loss of sufficient severity that it would not be adequately
remedied by a wearable hearing aid.
More than one bone anchored hearing aid per Covered Person who meets the above coverage
criteria during the entire period of time the Covered Person is enrolled under the Policy.
Repairs and/or replacement for a bone anchored hearing aid for Covered Persons who meet the
above coverage criteria, other than for malfunctions.
COC.EXC.I.11.NJ
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V. All Other Exclusions
1.
2.
3.
Health services and supplies that do not meet the definition of a Covered Health Service - see the
definition in Section 9: Defined Terms. Covered Health Services are those health services,
including services, supplies, or Pharmaceutical Products, which we determine to be all of the
following:



Physical, psychiatric or psychological exams, testing, vaccinations, immunizations or treatments
that are otherwise covered under the 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.

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.
Health services received as a result of war or any act of war:

as a result of war or an act of war, if the illness or Injury occurs while you are serving in any
civilian non-combatant unit supporting or accompany any military, naval or air forces of any
country, combination of countries or international organization; and

as a result of the special hazards incident to service in any civilian non-combatant unit
supporting or accompanying such forces, provided the illness or Injury occurs while you are
serving in such unit and are outside the United States and Canada.
Health services received as a result of war or any act of war while you are not in the military, naval
or air forces of any country, combination of countries or international organization or in any civilian
non-combatant unit supporting or accompanying such forces, if the illness or Injury occurs outside
the United States and Canada.
4.
Health services received after the date your coverage under the 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 the 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 the 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.
COC.EXC.I.11.NJ
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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.
COC.EXC.I.11.NJ
41
Section 3: When Coverage Begins
How to Enroll
Eligible Persons must complete an enrollment form. The Enrolling Group will give the necessary forms to
you. The Enrolling Group will then submit the completed forms to us, along with any required Premium.
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 the Policy. These Benefits will be paid by us unless they are being paid by a
prior carrier under such prior carrier's obligations with respect to extension of benefits 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. For Benefit plans that have a Network Benefit level, Network Benefits are
available only if you receive Covered Health Services from Network providers unless rendered to treat an
Emergency as described in the Emergency Services Benefit of the Covered Health Services section.
Covered Health Services received in accordance with the Emergency Services Benefit will be treated as
Network Benefits regardless of whether the services were rendered by a Network or a non-Network
provider.
Who is Eligible for Coverage
The Enrolling Group determines who is eligible to enroll under the Policy and who qualifies as a
Dependent. Please contact the Benefits Administrator of the Group for information on who they have
determined is eligible to enroll under this Policy.
Eligible Person
Eligible Person usually refers to an employee or member of the Enrolling Group who meets the eligibility
rules. When an Eligible Person actually enrolls, we refer to that person as a Subscriber. For a complete
definition of Eligible Person, Enrolling Group and Subscriber, see Section 9: Defined Terms.
Eligible Persons must reside within the United States.
If both spouses are Eligible Persons of the Enrolling Group, each may enroll as a Subscriber or be
covered as an Enrolled Dependent of the other, but not both.
Dependent
Dependent generally refers to the Subscriber'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 9: Defined Terms.
Dependents of an Eligible Person may not enroll unless the Eligible Person is also covered under the
Policy.
The term spouse also includes Civil Union Partners as defined by, and in accordance with New Jersey
law and the valid laws of another jurisdiction under which a civil union relationship was created.
COC.BGN.I.11.NJ
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If both parents of a Dependent child are enrolled as a Subscriber, only one parent may enroll the child as
a Dependent.
When Coverage Ends.
When to Enroll and When Coverage Begins
Except as described below, Eligible Persons may not enroll themselves or their Dependents.
Initial Enrollment Period
When the Enrolling Group purchases coverage under the Policy from us, the Initial Enrollment Period is
the first period of time when Eligible Persons can enroll themselves and their Dependents.
Coverage begins on the date identified in the Policy if we receive the completed enrollment form and any
required Premium within 31 days of the date the Eligible Person becomes eligible to enroll.
Open Enrollment Period
The Enrolling Group determines the Open Enrollment Period. During the Open Enrollment Period, Eligible
Persons can enroll themselves and their Dependents.
Coverage begins on the date identified by the Enrolling Group if we receive the completed enrollment
form and any required Premium within 31 days of the date the Eligible Person becomes eligible to enroll.
Dependent Child Special Open Enrollment Period
On or before the first day of the first plan year beginning on or after September 23, 2010, the Enrolling
Group will provide a 30 day dependent child special open enrollment period for Dependent children who
are not currently enrolled under the Policy and who have not yet reached the limiting age. During this
dependent child special open enrollment period, Subscribers who are adding a Dependent child and who
have a choice of coverage options will be allowed to change options.
Coverage begins on the first day of the plan year beginning on or after September 23, 2010, if we receive
the completed enrollment form and any required Premium within 31 days of the date the Dependent
becomes eligible to enroll under this special open enrollment period.
New Eligible Persons
Coverage for a new Eligible Person and his or her Dependents begins on the date agreed to by the
Enrolling Group if we receive the completed enrollment form and any required Premium within 31 days of
the date the new Eligible Person first becomes eligible.
Adding New Dependents
Subscribers may enroll Dependents who join their family because of any of the following events:

Birth. Coverage for a newborn child begins at the moment of birth and continues for 31 days as if
the child were enrolled, without additional Premium for these 31 days.

Legal adoption.


COC.BGN.I.11.NJ
43

Legal guardianship.

Court or administrative order.

Coverage for the Dependent begins on the date of the event if we receive the completed enrollment form
and any required Premium within 31 days of the event that makes the new Dependent eligible.
Special Enrollment Period
An Eligible Person and/or Dependent may also be able to enroll during a special enrollment period. A
special enrollment period is not available to an Eligible Person and his or her Dependents if coverage
under the prior plan was terminated for cause, or because premiums were not paid on a timely basis.
An Eligible Person and/or Dependent does not need to elect COBRA continuation coverage to preserve
special enrollment rights. Special enrollment is available to an Eligible Person and/or Dependent even if
COBRA is not elected.
A special enrollment period applies to an Eligible Person and any Dependents when one of the following
events occurs:

Birth.

Legal adoption.



A special enrollment period also applies for an Eligible Person and/or Dependent who did not enroll
during the Initial Enrollment Period or Open Enrollment Period if the following are true:

The Eligible Person previously declined coverage under the Policy, but the Eligible Person and/or
Dependent becomes eligible for a premium assistance subsidy under Medicaid or Children's Health
Insurance Program (CHIP). Coverage will begin only if we receive the completed enrollment form
and any required Premium within 60 days of the date of determination of subsidy eligibility.

The Eligible Person and/or Dependent had existing health coverage under another plan at the time
they had an opportunity to enroll during the Initial Enrollment Period or Open Enrollment Period;
and

Coverage under the prior plan ended because of any of the following:

Loss of eligibility (including legal separation, divorce, dissolution of a civil union, dissolution
of Domestic Partnership or Life Partnership or death).

The employer stopped paying the contributions. This is true even if the Eligible Person
and/or Dependent continues to receive coverage under the prior plan and to pay the
amounts previously paid by the employer.

In the case of COBRA continuation coverage, the coverage ended.

The Eligible Person and/or Dependent no longer lives or works in an HMO service area if no
other benefit option is available.
COC.BGN.I.11.NJ
44

The plan no longer offers benefits to a class of individuals that include the Eligible Person
and/or Dependent.

An Eligible Person and/or Dependent incurs a claim that would exceed a lifetime limit on all
benefits.

The Eligible Person and/or Dependent loses eligibility under Medicaid or Children's Health
Insurance Program (CHIP). Coverage will begin only if we receive the completed enrollment
form and any required Premium within 60 days of the date coverage ended.
When an event takes place (for example, a birth, marriage or determination of eligibility for state subsidy),
coverage begins on the date of the event if we receive the completed enrollment form and any required
Premium within 31 days of the event unless otherwise noted above.
For an Eligible Person and/or Dependent who did not enroll during the Initial Enrollment Period or Open
Enrollment Period because they had existing health coverage under another plan, coverage begins on
the day immediately following the day coverage under the prior plan ends. Except as otherwise noted
above, coverage will begin only if we receive the completed enrollment form and any required Premium
within 31 days of the date coverage under the prior plan ended.
COC.BGN.I.11.NJ
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Section 4: When Coverage Ends
General Information about When Coverage Ends
We may discontinue this Benefit plan and/or all similar benefit plans for the reasons explained in the
Policy, as permitted by law.
Unless you are entitled to Extended Coverage for Total Disability, your entitlement to Benefits
automatically ends on the date that coverage ends, even if you are otherwise receiving medical treatment
on that date. Please note that this does not affect coverage that is extended under Extended Coverage
for Total Disability below.
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). Please note that this does not affect coverage that is extended
under Extended Coverage for Total Disability below.
Unless otherwise stated, an Enrolled Dependent's coverage ends on the date the Subscriber's coverage
ends.
Events Ending Your Coverage
Coverage ends on the earliest of the dates specified below:

The Entire Policy Ends
Your coverage ends on the date the Policy ends. In the event the entire Policy ends, the Enrolling
Group is responsible for notifying you that your coverage has ended.

You Are No Longer Eligible
Your coverage ends on the date you are no longer eligible to be a Subscriber or Enrolled
Dependent. Please refer to Section 9: Defined Terms for complete definitions of the terms "Eligible
Person," "Subscriber," "Dependent" and "Enrolled Dependent". You must notify us when a child no
longer meets the requirements for Dependent coverage. If we are not notified, the Subscriber must
reimburse us for any Benefits that we pay for a child at a time when the child did not satisfy these
conditions. Refer to the definition of "Dependent" in Section 9: Defined Terms for requirements of
Dependent coverage.

We Receive Notice to End Coverage
Your coverage ends on the date we receive written notice from the Enrolling Group instructing us to
end your coverage, or the date requested in the notice, if later. The Enrolling Group is responsible
for providing written notice to us to end your coverage.

Subscriber Retires or Is Pensioned
Your coverage ends the date the Subscriber is retired or receiving benefits under the Enrolling
Group's pension or retirement plan. The Enrolling Group is responsible for providing written notice
to us to end your coverage.
This provision applies unless a specific coverage classification is designated for retired or
pensioned persons in the Enrolling Group's application, and only if the Subscriber continues to
meet any applicable eligibility requirements. The Enrolling Group can provide you with specific
information about what coverage is available for retirees.
COC.END.I.11.NJ
46
Other Events Ending Your Coverage
We will provide 30 days advance written notice to the Subscriber of a Rescission of coverage and that
coverage will end on the date we identify in the notice if any form of fraud or intentional misrepresentation
of a material fact.
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 false information relating to another person's eligibility or status as a
Dependent.
During the first two years the Policy is in effect, 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. In this case, we will also refund the Premiums that were paid to us for your coverage. After the first
two years, we can only demand that you pay back these Benefits if the written application contained a
fraudulent misstatement.
Coverage for a Disabled Dependent Child
Coverage for an unmarried Enrolled Dependent child who is not able to be self-supporting because of
mental retardation or a physical handicap 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 retardation or physical handicap or disability.

Depends mainly on the Subscriber for support.
Coverage will continue as long as the Enrolled Dependent is incapacitated and dependent unless
coverage is otherwise terminated in accordance with the terms of the Policy.
We will ask you to furnish us with proof of the incapacity and dependency 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 incapacity and dependency within 31 days of our request as
described above, coverage for that child will end.
Extended Coverage for Total Disability
Coverage for a Covered Person who is Totally Disabled on the date the entire Policy is terminated will not
end automatically. We will temporarily extend the coverage, only for treatment of the condition causing
the Total Disability. Benefits will be paid until the earlier of either of the following:

The Total Disability ends.

Twelve months from the date coverage would have ended when the entire Policy was terminated.

The date maximum Benefits under the Policy have been received.
COC.END.I.11.NJ
47
Continuation of Coverage and Conversion
If your coverage ends under the Policy, you may be entitled to elect continuation coverage (coverage that
continues on in some form) in accordance with federal or state law.
Continuation coverage under COBRA (the federal Consolidated Omnibus Budget Reconciliation Act) is
available only to Enrolling Groups that are subject to the terms of COBRA. You can contact your plan
administrator to determine if your Enrolling Group is subject to the provisions of COBRA.
If you selected continuation coverage under a prior plan which was then replaced by coverage under the
Policy, continuation coverage will end as scheduled under the prior plan or in accordance with federal or
state law, whichever is earlier.
We are not the Enrolling Group's designated "plan administrator" as that term is used in federal law, and
we do not assume any responsibilities of a "plan administrator" according to federal law.
We are not obligated to provide continuation coverage to you if the Enrolling Group or its plan
administrator fails to perform its responsibilities under federal law. Examples of the responsibilities of the
Enrolling Group or its plan administrator are:

Notifying you in a timely manner of the right to elect continuation coverage.

Notifying us in a timely manner of your election of continuation coverage.
Continuation Coverage under Federal Law (COBRA)
Much of the language in this section comes from the federal law that governs continuation coverage. You
should call your Enrolling Group's plan administrator if you have questions about your right to continue
coverage.
In order to be eligible for continuation coverage under federal law, you must meet the definition of a
"Qualified Beneficiary". A Qualified Beneficiary is any of the following persons who was covered under the
Policy on the day before a qualifying event:

An employee (also referred to as "Subscriber").

An Enrolled Dependent spouse of a Subscriber

An Enrolled Dependent child of the Subscriber. NOTE: If a covered Subscriber has a new child or
adopts a new child during the continuation period, such new child will also be treated as a Qualified
Beneficiary.
Per federal law, Civil Union Partners, Domestic Partners or Life Partners and their Eligible Dependents
are prohibited from obtaining COBRA continuation.
Qualifying Events for Continuation Coverage under Federal Law (COBRA)
The events listed below constitute “Qualifying Events” under COBRA. This means that if such event
occurs and results in a loss of coverage to the Qualified Beneficiary under the group health plan the
Qualified Beneficiary may be entitled to continue coverage for a certain period of time beyond the normal
termination date. In order to continue coverage under this section, the appropriate Premium contributions
must be made by (or on behalf of) the Qualified Beneficiary. Terminating Events for Continuation
Coverage under Federal Law (COBRA) to determine the length of the continuation period). The
Qualifying Events for an employee are as follows:
A. For Subscribers, the termination of employment with the Enrolling Group (termination can be
voluntary or involuntary but, if involuntary must be for any reason(s) other than gross misconduct),
or loss of coverage as a result of a reduction of hours; or
COC.END.I.11.NJ
48
B. For Enrolled Dependents, the death of the Subscriber; or
C. For the Enrolled Dependent spouse, the divorce or legal separation from the Subscriber; or
D. For the Enrolled Dependent children, the loss of eligibility under the terms of the group health
plan (e.g., reaching the maximum age); or
E. For Enrolled Dependents, the Subscriber's entitlement to Medicare benefits that results in a loss
of coverage for the Enrolled Dependents.
NOTE: Special rules apply for Enrolling Groups filing for bankruptcy, under Title XI, United States
Code. Please contact your Enrolling Group's plan administrator for additional details regarding
COBRA rights in the event of bankruptcy.
Notification Requirements and Election Period for Continuation Coverage under
Federal Law (COBRA)
The Subscriber or other Qualified Beneficiary must notify the Enrolling Group's designated plan
administrator within 60 days of the Subscriber's divorce, legal separation or an Enrolled Dependent's loss
of eligibility as an Enrolled Dependent. If the Subscriber or other Qualified Beneficiary fails to notify the
designated plan administrator of these events within the 60 day period, the Enrolling Group and its plan
administrator are not obligated to provide continued coverage to the affected Qualified Beneficiary. If a
Subscriber is continuing coverage under federal law, the Subscriber must notify the Enrolling Group's
designated plan administrator within 60 days of the birth or adoption of a child.
Continuation must be elected by the later of 60 days after the qualifying event occurs; or 60 days after the
Qualified Beneficiary receives notice of the continuation right from the Enrolling Group's designated plan
administrator.
If the Qualified Beneficiary's coverage was terminated due to a qualifying event, then the initial Premium
due to the Enrolling Group's designated plan administrator must be paid on or before the 45th day after
electing continuation.
Terminating Events for Continuation Coverage under Federal Law (COBRA)
Continuation under the Policy will end on the earliest of the following dates:
A. Eighteen months from the date of the qualifying event, if the Qualified Beneficiary's coverage
would have ended because the Subscriber's employment was terminated or hours were reduced
(i.e., qualifying event A.).
If a Qualified Beneficiary is determined to have been disabled under the Social Security Act at
anytime within the first 60 days of continuation coverage for qualifying event A. then the Qualified
Beneficiary may elect an additional 11 months of continuation coverage (for a total of 29 months of
continued coverage) subject to the following condition: (i) notice of such disability must be provided
within 60 days after the determination of the disability, and in no event later than the end of the first
18 months; (ii) the Qualified Beneficiary must agree to pay any increase in the required Premium
for the additional 11 months; and (iii) if the Qualified Beneficiary entitled to the 11 months of
coverage has non-disabled family members who are also Qualified Beneficiaries, then those nondisabled Qualified Beneficiaries are also entitled to the additional 11 months of continuation
coverage. Notice of any final determination that the Qualified Beneficiary is no longer disabled must
be provided within 30 days of such determination. Thereafter, continuation coverage may be
terminated on the first day of the month that begins more than 30 days after the date of that
determination.
COC.END.I.11.NJ
49
B. Thirty-six months from the date of the qualifying event for an Enrolled Dependent whose
coverage ended because of the death of the Subscriber, divorce or legal separation of the
Subscriber, loss of eligibility by an Enrolled Dependent who is a child (i.e. qualifying events B., C.,
or D).
C. For the Enrolled Dependents of a Subscriber who was entitled to Medicare prior to a qualifying
event that was due to either the termination of employment or work hours being reduced, eighteen
months from the date of the qualifying event, or, if later, 36 months from the date of the
Subscriber's Medicare entitlement. For Enrolled Dependents of a Subscriber who becomes eligible
for Medicare after the Subscriber’s qualifying event due to either termination of employment or
reduction in work hours, may be entitled to 36 months of continuation coverage from the date of the
Subscriber’s first qualifying event (subject to certain group health plan restrictions).
D. The date coverage terminates under the Policy for failure to make timely payment of the
Premium.
E. The date, after electing continuation coverage, that coverage is first obtained under any other
group health plan. If such coverage contains a limitation or exclusion with respect to any preexisting condition, continuation shall end on the date such limitation or exclusion ends. The other
group health coverage shall be primary for all health services except those health services that are
subject to the pre-existing condition limitation or exclusion.
F. The date, after electing continuation coverage, that the Qualified Beneficiary first becomes
entitled to Medicare, except that this shall not apply in the event that coverage was terminated
because the Enrolling Group filed for bankruptcy, (i.e. qualifying event F.)
G. The date the entire Policy ends.
H. The date coverage would otherwise terminate under the Policy as described in this section
under the heading Events Ending Your Coverage.
If a Qualified Beneficiary is entitled to 18 months of continuation and a second qualifying event occurs
during that time, the Qualified Beneficiary's coverage may be extended up to a maximum of 36 months
from the date coverage ended because employment was terminated or hours were reduced. If the
Qualified Beneficiary was entitled to continuation because the Enrolling Group filed for bankruptcy, (i.e.
qualifying event F) and the retired Subscriber dies during the continuation period, then the other Qualified
Beneficiaries shall be entitled to continue coverage for 36 months from the date of the Subscriber's death.
Terminating events B through G described in this section will apply during the extended continuation
period.
Continuation coverage for Qualified Beneficiaries whose continuation coverage terminates because the
Subscriber becomes entitled to Medicare may be extended for an additional period of time (see section
"C" above). Such Qualified Beneficiaries should contact the Enrolling Group's designated plan
administrator for information regarding the continuation period.
New Jersey Continuation Rights for Over-Age Dependents (NJCROD)
A dependent who has elected to continue his or her coverage under the group policy under which his or
her parent is currently covered pursuant to NJCROD shall not be entitled to further continue coverage
under COBRA when continuation pursuant to NJCROD ends. As used in this provision, "Over-Age
Dependent" means an Employee's child by blood or law who:

Has reached the limiting age as described in this Certificate of Coverage, under Section 10:
Definitions, but is less than 31 years of age;

Is not married or part of a civil union or part of a domestic partnership;

Has no Dependents of his or her own;
COC.END.I.11.NJ
50

Is either a resident of New Jersey or in enrolled as a Full-time Student at an accredited school; and

Is not covered under any other group or individual health benefits plan, group health plan, church
plan, or health benefits plan, and is not entitled to Medicare.
Eligibility for Continuation through NJCROD
If a Dependent child's group health benefits end or have ended due to his or her attainment of the limiting
age described in this Certificate of Coverage, he or she may elect to continue such benefits until his or
her 31st birthday, subject to the Conditions for Election, Election of Continuation and When Continuation
Ends sections below.
Conditions for Election - An Over-Age Dependent is only entitled to make an election for continued
coverage if all of the following conditions are met:

The Over-Age-Dependent must provide evidence of prior creditable coverage or receipt of benefits
under a group or individual health benefits plan, group health plan, church plan or health benefits
plan or Medicare. Such prior coverage must have been in effect on the date the Over-AgeDependent reached the limiting age, or at any time after such date but prior to making an election
for this Over-Age-Dependent coverage.

The Subscriber of an Over-Age Dependent must be enrolled as having elected Dependent
coverage at the time the Over-Age Dependent elects continued coverage. Except, if the employee
has no other Dependents, or has a spouse who is covered elsewhere, the Over-Age-Dependent
may nevertheless select continued coverage.
Election of Continuation - To continue health benefits, the Over-Age Dependent must make written
election to us. The effective date of the continued coverage will be the later of:

The date the Over-Age Dependent gives written notice to us;

The date the Over-Age Dependent pays the first premium; or

The date the Dependent would otherwise lose coverage due to the attainment of the limiting age.
For a Dependent whose coverage has not yet terminated due to reaching the limiting age stated in this
Certificate of Coverage, Section 9: Defined Terms - Dependent, the written election must be made within
30 days prior to termination of coverage due to the attainment of the limiting age.
For a person who did not qualify as an Over-Age Dependent because he or she fails to meet all the
requirements of an Over-Age Dependent, but who subsequently meets all of the requirements for an
Over-Age Dependent, written election must be made within 30 days after the person first subsequently
meets all of the requirements for an Over-Age Dependent.
This election opportunity is explained in greater detail as follows:

If a person did not qualify because he or she was married or part of a civil union, the notice must be
given within 30 days of the date he or she is no longer married.

If a person did not qualify because he or she had a Dependent of his or her own, the election must
be made within 30 days of the date her or she no longer has a Dependent.

If a person did not qualify because he or she either was not a resident of New Jersey or was not a
Full-time student at an accredited school, the election must be made within 30 days of the date he
or she becomes a resident a New Jersey, or becomes a Full-time Student at an accredited school.

If a person did not qualify because he or she was covered under an other group or individual health
benefits plan, group health plan, church plan or health benefits plan, or was entitled to Medicare,
the election must be made within 30 days of the date he or she is no longer covered under any
other group or individual health benefits plan, group health plan, church plan or health benefits
plan, or is no longer entitled to Medicare.
COC.END.I.11.NJ
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Each year there will be an Open Enrollment Period during which an Over-Age Dependent, who previously
did not elect to continue coverage, may make an election to continue coverage. A group Open Enrollment
Period will be held at least annually.
Application of a Pre-Existing Conditions Exclusion
An Over-Age Dependent who was covered under prior creditable coverage that terminated no more than
90 days prior to making an election for continuation under this section will be given credit for the time he
or she was covered under the credible coverage toward the application of the Pre-Existing Conditions
Exclusion under the Policy.
Premium Payments
The first month's Premium must be paid within 30 days of the date the Over-Age Dependent elects
continued coverage.
The Over-Age Dependent must pay subsequent Premiums monthly, in advance, at the times and in the
manner specified by us. The monthly Premium will be set by us, and must be consistent with the
requirements of P.L. 2005, c.375.
Continued Benefits
The continued benefits shall be identical to the coverage provided to the Over-Age Dependent's
Subscriber who is covered as an Employee under the Policy. If coverage is modified for Dependents who
are under the limiting age, the coverage for Over-Age Dependent's Subscriber who is covered as an
employee under the Policy. If coverage is modified for Dependents who are under the limiting age, the
coverage for Over-Age Dependents shall also be modified in the same manner. Evidence of insurability is
not required for the continued coverage.
When Continuation Ends
An Over-Age Dependent's continued group health benefits end on the first of the following:

The date the Over-Age Dependent:

Attains age 31;

Marries or enters a civil union;

Acquires a Dependent;

Is no longer either a resident of New Jersey or enrolled as a Full-time Student at an
accredited school; or

Becomes covered under any other group or individual health benefits plan, group health
plan, church plan or health benefits plan, or becomes entitled to Medicare.

The end of the period for which Premium has been paid for the Over-Age Dependent, subject to
the grace period for such payment;

The date the Policy ceases to provide coverage to the Over-Age Dependent's Subscriber who is
the employee under the Policy.

The date the Policy under which the Over-Age Dependent elected to continue coverage is
amended to delete coverage for Dependents.

The date the Over-Age Dependent's Subscriber who is covered as an Employee under the Policy
waives Dependent coverage. Except if the Subscriber has no other Dependents, the Over-Age
Dependent's coverage will not end as a result of the Subscriber waiving Dependent coverage.
COC.END.I.11.NJ
52
State Continuation of Coverage for Totally Disabled Subscribers
If a Subscriber's coverage stops because his or her employment ends and the Subscriber meets the
conditions shown below, the Subscriber may choose to continue the coverage then in effect. The
Subscriber must meet the following conditions:

The Subscriber's employment ended because he or she is Totally Disabled.

The Subscriber must have been covered under the Policy for at least three months before his or
her coverage would have stopped.

The Subscriber must choose to continue coverage within 31 days after the date his or her coverage
would have stopped.

The Subscriber will have to make payments to the Enrolling Group for the coverage.
Coverage will stop on the earliest of the following:

The date the Subscriber becomes employed and eligible for another plan of group health coverage.

The date coverage ends for failure to make timely payment of the Premium.

The date the Policy ends.
"Totally Disabled" for the purpose of this state continuation means the Subscriber's complete inability due
to Injury or Sickness to engage in any and every gainful occupation for which the Subscriber is or
becomes reasonably fitted by education, training or experience and that the Subscriber is not engaged in
any gainful occupation.
Optional State Continuation of Coverage After the Subscriber's Death
If the Subscriber dies while covered, his or her Dependents' coverage may continue. It will continue with
the same benefits and provisions that the Subscriber's Dependents had while the Subscriber was alive. It
will continue only while the Policy is in force. It will stop on the earlier of the following:

The date of the Subscriber's widow's or widower's death, or the date the last child stops being an
eligible Dependent, whichever happens later.

180 days after the date of the Subscriber's death.
The Subscriber's Dependents will have to make payments to the Enrolling Group for the coverage.
After the Subscriber's widow's or widower's death, coverage for the Subscriber's Dependent children may
be continued. It will continue with the same Benefits and provisions that the Subscriber's Dependents had
while the Subscriber's widow or widower was alive. It will continue according to the rules and time limits
described above.
Conversion
If your coverage terminates for one of the reasons described below, you may apply for conversion
coverage without furnishing evidence of insurability.
Reasons for termination:

The Subscriber is retired or pensioned.

You cease to be eligible as a Subscriber or Enrolled Dependent.

Continuation coverage ends.
COC.END.I.11.NJ
53

The entire Policy ends and is not replaced.
If your marriage or civil union is dissolved, the Subscriber's former spouse may buy conversion coverage.
The conversion coverage will be an individual policy. The Subscriber's former spouse may apply for
conversion coverage at either of the following times:

The date the marriage or civil union is dissolved.

At the end of any period of continuation of coverage under the Policy, but only if the Policy is in
force on that date.
Application and payment of the initial Premium must be made within 31 days after coverage ends under
the Policy. Conversion coverage will be issued in accordance with the terms and conditions in effect at
the time of application. Conversion coverage may be substantially different from coverage provided under
the Policy.
COC.END.I.11.NJ
54
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, if you make an assignment of
Benefits, the non-Network provider is responsible for requesting payment from us. The non-Network
provider must file the claim on the standard claim form prescribed by New Jersey that contains all of the
information we require, as described below. At your option, you may also submit the claim to us directly.
Your non-Network provider should submit a request for payment of Benefits within 60 days after the date
of service. If you have assigned benefits to the non-Network provider, as described below, the nonNetwork provider should submit a request for payment of Benefits within 180 days after the date of
service. If this information is not provided to us within one year of the date of service, Benefits for that
health service will be denied or reduced, subject to the appeal provisions in Section 6, Questions,
Complaints and Appeals. This time limit does not apply if it was not reasonably possible to submit the
request in the time required and the request was submitted as soon as reasonably possible. If your claim
relates to an Inpatient Stay, the date of service is the date your Inpatient Stay ends.
Required Information
When you request payment of Benefits from us, We will provide you with the appropriate forms to submit
proof of loss. You must submit the completed form to us with all of the following information:

The Subscriber'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.
If you do not receive the forms for proof of loss within 15 days of our receipt of notice of a claim, you may
submit written proof of loss describing the occurrence, character and extent of the loss for which the claim
is being made.
COC.CLM.I.11.NJ
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Payment of Benefits
We will pay Benefits within the time frames shown below after we receive a request for payment that
includes all required information.

30 days after we receive a request submitted by electronic means.

40 days after we receive a request submitted by other than electronic means.
Requests for payment that include all required information which are not paid within these time frames will
include an overdue payment of simple interest at the rate of 12% per annum.
If a Subscriber provides written authorization to allow this, all or a portion of any Eligible Expenses due to
a provider will be paid directly to the provider instead of being paid to the Subscriber. But we will not
reimburse third parties that have purchased or been assigned benefits by Physicians or other providers.
Benefits will be paid to you unless either of the following is true:

The provider notifies us that your signature is on file, assigning benefits directly to that provider.

You make a written request at the time you submit your claim.
When an assignment is not obtained, we will send the reimbursement directly to you (the Subscriber) for
you to reimburse them upon receipt of their bill. We will, however, pay a non-Network provider directly for
services rendered to you if you provide written authorization to allow this. In the case of any such
assignment of Benefits or payment to a non-Network provider, we reserve the right to offset Benefits to be
paid to the provider by any amounts that the provider owes us for a maximum of eighteen months. You
will not be held responsible for payment of any offset amounts.
When you assign your Benefits under the Policy to a non-Network provider, and the non-Network provider
submits a claim for payment, you and the non-Network provider represent and warrant the following:

The Covered Health Services were actually provided.

The Covered Health Services were medically appropriate.
In accordance with New Jersey law, a consumer may request a review from the Ombudsman of any
disputed insurance claim settlement where there is reasonable cause to believe than an insurer has failed
or refused to settle a claim in accordance with the provisions of the policy. Consumers seeking a review
must file a complaint with the Ombudsman in any form, which indicates that the complainant is seeking
review of a disputed claim. All complaints must be sent to:
The Office of Insurance Claims Ombudsman
20 West State Street
P.O. Box 472
Telephone: (800)446-7467
Telefax: (609)292-2431
Email: [email protected]
COC.CLM.I.11.NJ
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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
What to Do if You Have a Complaint
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 30 days of receiving it.
If you are not satisfied with our decision, you have the right to take your complaint to the Department of
Banking and Insurance.
An Adverse Benefit Determination means a denial, reduction, or termination of, or a failure to provide or
make a payment (in whole or in part) for a benefit, including any such denial, reduction, termination, or
failure to provide or make a payment that is based on: a determination of an individual's eligibility to
participate in a plan or health insurance coverage; a determination that a benefit is not a covered benefit;
the imposition of a preexisting condition exclusion, source-of-injury exclusion, network exclusion, or other
limitation on otherwise covered benefits; a determination that a benefit is experimental, investigational, or
not medically necessary or appropriate; or a rescission of coverage.
A Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been
upheld by a plan or issuer at the completion or exhaustion of the internal appeals process.
You have the right to appeal an Adverse Benefit Determination or Final Internal Adverse Benefit
Determination. You may write or call us within 60 days of the decision asking that it be reconsidered. You
may also designate a representative (like your Physician) to appeal on your behalf. You will receive a
written notice of the decision within 5 business days of the date we receive all of the necessary
information to process your appeal. This notice will include the reasons for the determination and, if the
original decision is upheld, the clinical rationale for the decision.
If you are still unsatisfied with our decision, you can ask us in writing to formally reconsider your appeal.
You have the right to request (free of charge) documents relevant to your claim and/or appeal and to
present evidence. You have the right to receive the rationale or new evidence relied upon in connection
with the claim in advance of the date we must provide notice of our decision.
Post-service Claims
received.
COC.CPL.I.11.NJ
57
Pre-service requests for Benefits are those requests that require prior authorization or benefit
confirmation prior to receiving medical care.
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:





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
and free of charge, you have the right to reasonable access to and copies of all documents, records and
Action below.

conducted and you will be notified of the decision within 5 days from receipt of a request for appeal
of a denied request for Benefits. If you are not satisfied with the first level appeal decision, you
have the right to request a second level appeal. Your second level appeal request must be
submitted to us within 60 days from receipt of the first level appeal decision. The second level
appeal will be conducted and you will be notified of the decision within 20 business days from
receipt of a request for review of the first level appeal decision. The second level appeal process
will provide you (or your provider, if applicable) the opportunity to pursue your appeal before a
panel of Physicians and/or other providers that we select who have not been previously involved in
the decision being appealed.
COC.CPL.I.11.NJ
58

you will be notified of the decision within 5 business days from receipt of a request for appeal of a
denied claim. If you are not satisfied with the first level appeal decision, you have the right to
request a second level appeal. Your second level appeal request must be submitted to us within 60
days from receipt of the first level appeal decision. The second level appeal will be conducted and
you will be notified of the decision within 20 business days from receipt of a request for review of
the first level appeal decision.
Our decision is based on whether or not Benefits are available under the Policy for the proposed
treatment or procedure.
Your appeal may require immediate action if you have a non-life-threatening condition that requires care
by a provider within 24 hours. In these urgent situations:

as possible.


If we need more information from your Physician to make a decision, we will notify you of the
decision by the end of the next business day following receipt of the required information.
The appeal process for urgent situations does not apply to prescheduled treatments, therapies or
surgeries.
External Review Program
If you are not satisfied with the results of the appeal process, you have the right to appeal the denial
through the Independent Health Care Appeals Program. The written notification of the denial will include
an application for external review with instructions.
You must send the application to the address shown below within 60 days of receipt of the written
notification of the denial.
Department of Banking and Insurance
Consumer Protection Services
Office of Managed Care
PO Box 325
The application fee is $25. If there is financial hardship the reduced fee is $2. The Department of Banking
and Insurance determines financial hardship based on evidence that one or more members of your
household is receiving assistance from the Pharmaceutical Assistance to the Aged and Disabled
program, Medicaid, NJ FamilyCare, General Assistance, SSI, or New Jersey Unemployment Assistance.
We pay for the cost of the external appeal.
The decision of the Independent Health Care Appeals Program will be binding on us.
Rescission of coverage does not qualify for external review.
COC.CPL.I.11.NJ
59
Section 7: Coordination of Benefits
Benefits When You Have Coverage under More than One Plan
This section describes how Benefits under the Policy will be coordinated with those of any other plan that
provides benefits to you.
When Coordination of Benefits Applies
This coordination of benefits (COB) provision applies when a person has health care coverage under
more than one Plan. Plan is defined below. For instance, you may be covered by this Certificate as an
employee and by another Plan as a Dependent of your spouse. If you are covered by more than one
Plan, this provision allows us to coordinate what we pay or provide with what another Plan pays or
provides. This provision sets forth the rules for determining which is the Primary Plan and which is the
Secondary Plan. Coordination of benefits is intended to avoid duplication of benefits while at the same
time preserving certain rights to coverage under all Plans under which you are covered.
Definitions
The words shown below have special meanings when used in this provision. Please read these
definitions carefully. Throughout this provision, these defined terms appear with their initial letter
capitalized.
Allowable Expense - The charge for any health care service, supply or other item of expense for which
you are liable when the health care service, supply or other item of expense is covered at least in part
under any of the Plans involved, except where a statute requires another definition, or as otherwise stated
below.
When this Plan is coordinating benefits with a Plan that provides benefits only for dental care, vision care,
prescription drugs or hearing aids, Allowable Expense is limited to like items of expense.
We will not consider the difference between the cost of a private Hospital room and that of a semi-private
Hospital room as an Allowable Expense unless the stay in a private room is Medically Necessary and
appropriate.
When this Plan is coordinating benefits with a Plan that restricts coordination of benefits to a specific
coverage, we will only consider corresponding services, supplies or items of expense to which
coordination of benefits applies as an Allowable Expense.
Claim Determination Period - A calendar year, or any portion of a calendar year, during which you are
covered by this Plan and at least one other Plan and incur one or more Allowable Expense(s) under such
Plans.
Plan - Coverage with which coordination of benefits is allowed. Plan includes:

Group insurance and group Subscriber contracts, including insurance continued pursuant to a
federal or state continuation law;

Self-funded arrangements of group or group-type coverage, including insurance continued
pursuant to a federal or state continuation law;

Group or group-type coverage through a health maintenance organization (HMO) or other
prepayment, group practice and individual practice plans, including insurance continued pursuant
to a federal or state continuation law;

Group hospital indemnity benefit amounts that exceed $150.00 per day;
COC.COB.I.11.NJ
60

Medicare or other governmental benefits, except when, pursuant to law, the benefits must be
treated as in excess of those of any private insurance Plan or non-governmental Plan.
Plan does not include:

Individual or family insurance contracts or Subscriber contracts;

Individual or family coverage through a health maintenance organization or under any other
prepayment, group practice and individual practice Plans;

Group or group-type coverage where the cost of coverage is paid solely by you except that
coverage being continued pursuant to a federal or state continuation law shall be considered a
Plan;

Group hospital indemnity benefit amounts of $150.00 per day or less;

School accident-type coverage;

A state Plan under Medicaid.
Primary Plan - A Plan whose benefits for your health care coverage must be determined without taking
into consideration the existence of any other Plan. There may be more than one Primary Plan. A Plan will
be the Primary Plan if either of the below exist:

The Plan has no order of benefit determination rules, or it has rules that differ from those contained
in this Coordination of Benefits provision; or

All Plans which cover you use order of benefit determination rules consistent with those contained
in the Coordination of Benefits provision and under those rules, the plan determines its benefits
first.
Reasonable and Customary - An amount that is not more than the usual or customary charge for the
service or supply as determined by us, based on a standard which is most often charged for a given
service by a provider within the same geographic area.
Secondary Plan - A Plan which is not a Primary Plan. If you are covered by more than one Secondary
Plan, the order of benefit determination rules of this Coordination of Benefits provision shall be used to
determine the order in which the benefits payable under the multiple Secondary Plans are paid in relation
to each other. The benefits of each Secondary Plan may take into consideration the benefits of the
Primary Plan or Plans and the benefits of any other Plan which, under this Coordination of Benefits
provision, has its benefits determined before those of that Secondary Plan.
Primary and Secondary Plan
We consider each Plan separately when coordinating payments.
The Primary Plan pays or provides services or supplies first, without taking into consideration the
existence of a Secondary Plan. If a Plan has no coordination of benefits provision, or if the order of
benefit determination rules differ from those set forth in these provisions, it is the Primary Plan.
A Secondary Plan takes into consideration the benefits provided by a Primary Plan when, according to
the rules set forth below, the Plan is the Secondary Plan. If there is more than one Secondary Plan, the
order of benefit determination rules determine the order among the Secondary Plans. During each claim
determination period the Secondary Plan(s) will pay up to the remaining unpaid Allowable Expenses, but
no Secondary Plan will pay more than it would have paid if it had been the Primary Plan. The method the
Secondary Plan uses to determine the amount to pay is set forth below in the "Procedures to be Followed
by the Secondary Plan to Calculate Benefits" section of this provision.
COC.COB.I.11.NJ
61
The Secondary Plan shall not reduce Allowable Expenses for Medically Necessary and appropriate
services or supplies on the basis that precertification, preapproval, notification or second surgical opinion
procedures were not followed.
Order of Benefit Determination Rules
The benefits of the Plan that covers you as an employee, member, Subscriber or retiree shall be
determined before those of the Plan that covers you as a Dependent. The coverage as an employee,
member, Subscriber or retiree is the Primary Plan.
The benefits of the Plan that covers you as an employee who is neither laid off nor retired, or as a
Dependent of such person, shall be determined before those for the Plan that covers you as a laid off or
retired employee, or as such a person's Dependent. If the other Plan does not contain this rule, and as a
result the Plans do not agree on the order of benefit determination, this portion of this provision shall be
ignored.
The benefits of the Plan that covers you as an employee, member, Subscriber or retiree, or Dependent of
such person, shall be determined before those of the Plan that covers you under a right of continuation
pursuant to federal or state law. If the other Plan does not contain this rule, and as a result the Plans do
not agree on the order of benefit determination, this portion of this provision shall be ignored.
If a child is covered as a Dependent under Plans through both parents, and the parents are neither
separated nor divorced, the following rules apply:

The benefits of the Plan of the parent whose birthday falls earlier in the Calendar year shall be
determined before those of the parent whose birthday falls later in the Calendar year.

If both parents have the same birthday, the benefits of the Plan which covered the parent for a
longer period of time shall be determined before those of the Plan which covered the other parent
for a shorter period of time.

"Birthday," as used above, refers only to month and day in a calendar year, not the year in which
the parent was born.

If the other Plan contains a provision that determines the order of benefits based on the gender of
the parent, the birthday rule in this provision shall be ignored.
If a child is covered as a Dependent under Plans through both parents, and the parents are separated or
divorced, the following rules apply:

The benefits of the Plan of the parent with custody of the child shall be determined first.

The benefits of the Plan of the spouse of the parent with custody shall be determined second.

The benefits of the Plan of the parent without custody shall be determined last.

If the terms of a court decree state that one of the parents is responsible for the health care
expenses for the child, and if the entity providing coverage under that Plan has actual knowledge of
the terms of the court decree, then the benefits of that Plan shall be determined first. The benefits
of the Plan of the other parent shall be considered as secondary. Until the entity providing
coverage under the Plan has knowledge of the terms of the court decree regarding health care
expenses, this portion of this provision shall be ignored.
If the above order of benefits does not establish which Plan is the Primary Plan, the benefits of the Plan
that covers the employee, member or Subscriber for a longer period of time shall be determined before
the benefits of the Plan(s) that covered the person for a shorter period of time.
COC.COB.I.11.NJ
62
Effect on the Benefits of This Plan
In order to determine which procedure to follow it is necessary to consider:

The basis on which the Primary Plan and the Secondary Plan pay benefits; and

Whether the provider who provides or arranges the services and supplies is in the Network of
either the Primary Plan or the Secondary Plan.
Benefits may be based on the Reasonable and Customary Charge (R&C), or some similar term. This
means that the provider bills a charge and you may be held liable for the full amount of the billed charge.
In this section, a Plan that bases benefits on a reasonable and customary charge is called an "R&C Plan."
Benefits may be based on a contractual fee schedule, sometimes called a negotiated fee schedule, or
some similar term. This means that although a provider, called a Network provider, bills a charge, you
may be held liable only for an amount up to the negotiated fee. In this section, a Plan that bases benefits
on a negotiated fee schedule is called a "Fee Schedule Plan." If you use the services of a non-Network
provider, the Plan will be treated as an R&C Plan even though the Plan under which you are covered
allows for a fee schedule.
Payment to the provider may be based on a "capitation". This means that the HMO or other Plan pays the
provider a fixed amount per Covered Person. You are liable only for the applicable deductible,
Coinsurance or Copayment. If you use the services of a non-Network provider, the HMO or other Plan will
only pay benefits in the event of emergency care or urgent care. In this section, a Plan that pays
providers based upon capitation is called a "Capitation Plan."
In the rules below, "provider" refers to the provider who provides or arranges the services or supplies and
"HMO" refers to a health maintenance organization plan.
Primary Plan is R&C Plan and Secondary Plan is R&C Plan
The Secondary Plan shall pay the lesser of:

The difference between the amount of the billed charges and the amount paid by the Primary Plan;
or

When the benefits of the Secondary Plan are reduced as a result of this calculation, each benefit shall be
reduced in proportion, and the amount paid shall be charged against any applicable benefit limit of the
Plan.
Primary Plan is Fee Schedule Plan and Secondary Plan and Secondary Plan is Fee Schedule Plan
If the provider is a Network provider in both the Primary Plan and the Secondary Plan, the Allowable
Expense shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of:


The total amount the provider receives from the Primary Plan, the Secondary Plan and you shall not
exceed the fee schedule of the Primary Plan. In no event shall you be responsible for any payment in
excess of the Copayment, Coinsurance or deductible of the Secondary Plan.
Primary Plan is R&C Plan and Secondary Plan is Fee Schedule Plan
If the provider is a Network provider in the Secondary Plan, the Secondary Plan shall pay the lesser of:

The difference between the amount of the billed charges for the Allowable Expenses and the
amount paid by the Primary Plan; or
COC.COB.I.11.NJ
63

You shall only be liable for the Copayment, deductible or Coinsurance under the Secondary Plan if you
have no liability for Copayment, deductible or Coinsurance under the Primary Plan and the total payments
by both the Primary and Secondary Plans are less than the provider's billed charges. In no event shall
you be responsible for any payment in excess of the Copayment, Coinsurance or deductible of the
Secondary Plan.
Primary Plan is Fee Schedule Plan and Secondary Plan is R&C Plan
If the provider is a Network provider in the Primary Plan, the Allowable Expense considered by the
Secondary Plan shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser
of:


Primary Plan is Fee Schedule Plan and Secondary Plan is R&C Plan or Fee Schedule Plan
provider is not considered as urgent care or emergency care, the Secondary Plan shall pay benefits as if
it were the Primary Plan.
Primary Plan is Capitation Plan and Secondary Plan is Fee Schedule Plan or R&C Plan
If you receive services or supplies from a provider who is in the Network of both the Primary Plan and the
Secondary Plan, the Secondary Plan shall pay the lesser of:


Primary Plan is Capitation Plan or Fee Schedule Plan or R&C Plan and Secondary Plan is
Capitation Plan
If you receive services or supplies from a provider who is in the Network of the Secondary Plan, the
Secondary Plan shall be liable to pay the capitation to the provider and shall not be liable to pay the
deductible, Coinsurance or Copayment imposed by the Primary Plan. You shall not be liable to pay any
deductible, Coinsurance or Copayments of either the Primary Plan or the Secondary Plan.
Primary Plan is an HMO and Secondary Plan is an HMO
provider is not considered as urgent care or emergency care, but the provider is in the Network of the
Secondary Plan, the Secondary Plan shall pay benefits as if it were the Primary Plan, except that the
Primary Plan shall pay out-of-Network services, if any, authorized by the Primary Plan.
COC.COB.I.11.NJ
64
Section 8: 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 Enrolling Group's Benefit plan and how it may affect you.
We help finance or administer the Enrolling Group's Benefit plan in which you are enrolled. We do not
provide medical services or make treatment decisions. This means:

We communicate to you decisions about whether the Enrolling Group's Benefit plan 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 Certificate.

The plan may not pay for all treatments you or your Physician may believe are necessary. If the
plan 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 and Enrolling Groups
The relationships between us and Network providers and Enrolling Groups are solely contractual
relationships between independent contractors. Network providers and Enrolling Groups are not our
agents or employees. Neither we nor any of our employees are agents or employees of Network
providers or the Enrolling Groups.
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 unless:

It is determined by a court of law under the provisions of the New Jersey Health Care Carrier
Accountability Act, 2001 that the provider acted as our agent and that we had the right to exercise
influence or control, or actually exercised influence or control over the health care treatment
decisions of that provider.

The other elements for establishing our liability under the Act are proven.
We are not considered to be an employer for any purpose with respect to the administration or provision
of benefits under the Enrolling Group's Benefit plan. We are not responsible for fulfilling any duties or
obligations of an employer with respect to the Enrolling Group's Benefit plan.
The Enrolling Group is solely responsible for all of the following:

Enrollment and classification changes (including classification changes resulting in your enrollment
or the termination of your coverage).

The timely payment of the Policy Charge to us.

Notifying you of the termination of the Policy.
COC.LGL.I.11.NJ
65
When the Enrolling Group purchases the Policy to provide coverage under a benefit plan governed by the
Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. §1001 et seq., we are not the plan
administrator or named fiduciary of the benefit plan, as those terms are used in ERISA. If you have
questions about your welfare benefit plan, you should contact the Enrolling Group. If you have any
questions about this statement or about your rights under ERISA, contact the nearest area office of the
Employee Benefits Security Administration, U. S. Department of Labor.
Your Relationship with Providers and Enrolling Groups
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.
The relationship between you and the Enrolling Group is that of employer and employee, Dependent or
other classification as defined in the Policy.
Notice
When we provide written notice regarding administration of the Policy to an authorized representative of
the Enrolling Group, that notice is deemed notice to all affected Subscribers and their Enrolled
Dependents. The Enrolling Group is responsible for giving notice to you.
Statements by Enrolling Group or Subscriber
All statements made by the Enrolling Group or by a Subscriber shall be deemed representations and not
warranties. Except for fraudulent statements, we will not use any statement made by the Enrolling Group
to void the Policy unless it is contained in a written application signed by the Enrolling Group. No such
statement shall void or reduce coverage under the Policy or be used in defense of a legal action unless it
is contained in a written application signed by the group or a Subscriber, as applicable.
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.
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
COC.LGL.I.11.NJ
66
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, they do not alter or affect your Benefits and are subject to change
without notice. Contact us if you have any questions.
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
Subject to your appeal rights set forth in the Questions, Complaints and Appeals Procedures Section, we

Make initial interpretations of Benefits under the Policy.

Make initial interpretations of the other terms, conditions, limitations and exclusions set out in the
Policy, including this Certificate, the Schedule of Benefits and any Riders and/or Amendments.

Make factual determinations related to the Policy and its Benefits.
We may delegate this authority to other persons or entities that provide services in regard to the
administration of the Policy.
This discretionary authority to interpret Benefits, other terms, conditions, limitations and exclusions under
the Policy is subject to modification or reversal by a court or regulatory agency with appropriate
jurisdiction.
It does not alter or affect your rights under state or federal statutes or regulations, including the right to
bring legal action against us. It does not alter or affect your rights to make a complaint or appeal a denial,
including use of the Independent Health Care Appeals Program.
In certain circumstances, for purposes of overall cost savings or efficiency, we may, in our discretion, 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.
Administrative Services
We may, in our sole discretion, arrange for various persons or entities to provide administrative services
in regard to the Policy, such as claims processing. The identity of the service providers and the nature of
COC.LGL.I.11.NJ
67
the services they provide may be changed from time to time in our sole discretion. 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.
Amendments to the Policy
Any provision of the Policy which, on its effective date, is in conflict with the requirements of state or
federal statutes or regulations (of the jurisdiction in which the Policy is delivered) is hereby amended to
conform to the minimum requirements of such statutes and regulations.
No other change may be made to the Policy unless it is made by an Amendment or Rider which has been
signed by one of our officers and the Enrolling Group. All of the following conditions apply:

Amendments to the Policy are effective 31 days after we send written notice to the Enrolling Group.

Riders are effective on the date we specify.

No agent has the authority to change the Policy or to waive any of its provisions.

No one has authority to make any oral changes or amendments to the Policy.
Any subsequent changes in Benefits will be shown in a Rider or Amendment issued to Subscribers.
Information and Records
We may use your individually identifiable health information to administer the 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 the 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 Subscriber'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 the 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 the Policy, we and our
related entities may use and transfer the information gathered under the 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.
COC.LGL.I.11.NJ
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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 the Policy do not substitute for and do not affect any requirements for coverage
by workers' compensation insurance.
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 the Policy.

All or some of the payment was made in error.
Except in cases of fraudulent claims, we will make a written request for the reimbursement no later than
18 months after the date the first payment of the claim was made. The refund equals the amount we paid
in excess of the amount we should have paid under the Policy. If the refund is due from another person or
organization, the Covered Person agrees to help us get the refund when requested.
In seeking reimbursement for the overpayment from the health care provider, we will not collect or attempt
to collect:

the funds for the reimbursement on or before the 45th calendar day following the submission of the
reimbursement request to the health care provider;

the funds for the reimbursement if the health care provider disputes the request and initiates an
appeal on or before the 45th calendar day following the submission of the reimbursement request
to the health care provider and until the health care provider's rights to appeal are exhausted; or

a monetary penalty against the reimbursement request, including but not limited to, an interest
charge or a late fee.
We may collect the funds for the reimbursement request by assessing them against payment of any
future claims submitted by the health care provider after the 45th calendar day following the submission
of the reimbursement request to the health care provider or after the health care provider's rights to
appeal have been exhausted if we submit an explanation in writing to the provider in sufficient detail so
that the provider can reconcile each Covered Person's bill.
If we determine that the overpayment to the health care provider is a result of fraud committed by the
health care provider and we have conducted its investigation and reported the fraud to the Office of the
Insurance Fraud Prosecutor as required by law, we may collect an overpayment by assessing it against
payment of any future claim submitted by the health care provider.
Limitation of Action
No legal action may be brought against us prior to the expiration of 60 days after proof of loss has been
filed. Additionally, 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.
COC.LGL.I.11.NJ
69
Entire Policy
The Policy issued to the Enrolling Group, including this Certificate, the Schedule of Benefits, the Enrolling
Group's application and any Riders and/or Amendments, constitutes the entire Policy.
COC.LGL.I.11.NJ
70
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.
An Alternate Facility may also provide Mental Health Services, Neurobiological Disorder - Autism
Spectrum Disorder Services or Substance Use Disorder Services on an outpatient or inpatient basis.
Amendment - any attached written description of additional or alternative provisions to the Policy.
Amendments are effective only when signed by us and the Enrolling Group. Amendments are subject to
all conditions, limitations and exclusions of the Policy, except for those that are specifically amended.
Annual Deductible - for Benefit plans that have an 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. Refer to the Schedule of
Benefits to determine whether or not your Benefit plan is subject to payment of an Annual Deductible and
for details about how the Annual Deductible applies.
Autism Spectrum Disorders - a group of neurobiological disorders that includes Autistic Disorder,
Rhett's Syndrome, Asperger's Disorder, Childhood Disintegrated Disorder and Pervasive Development
Disorders Not Otherwise Specified (PDDNOS).
Behavioral Interventions Based on ABA - interventions or strategies based upon learning theory that
are intended to improve socially important behavior of an individual using instructional and environmental
modifications that have been evaluated through scientific research using reliable and objective
measurements, including the empirical identification of functional relations between behavior and
environmental factors. Behavior intervention strategies based on ABA include, but are not limited to:

chaining;

functional analysis;

functional assessment;

functional communication training;

modeling, including video modeling (also known as imitation training);

procedures designed to reduce challenging and dangerous behaviors (e.g. differential
reinforcement, extinction, time out, and response cost);

prompting; and

reinforcement systems, including differential reinforcement, shaping and strategies to promote
generalization.
Benefits - your right to payment for Covered Health Services that are available under the Policy. Your
right to Benefits is subject to the terms, conditions, limitations and exclusions of the Policy, including this
Certificate, the Schedule of Benefits and any attached Riders and/or Amendments.
Biologically-Based Mental Illness - a mental or nervous condition that is caused by a biological disorder
of the brain and results in a clinically significant or psychological syndrome or pattern that substantially
COC.DEF.I.11.NJ
71
limits the functioning of the person with the illness, including but not limited to, schizophrenia,
schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic
disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder or
autism.
Civil Union Partners - an individual who is a partner in a civil union. A "civil union" is defined as, the
legally recognized union of two eligible individuals, of the same sex, established pursuant to (or otherwise
compliant with) New Jersey law. A civil union also includes relationships entered into under the laws of
other jurisdictions provided such relationships provide substantially all of the rights and benefits of
marriage.
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 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:

Medically Necessary or medically appropriate.


Covered Person - either the Subscriber or an Enrolled Dependent, but this term applies only while the
person is enrolled under the Policy. References to "you" and "your" throughout this Certificate 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 Subscriber's legal spouse, Civil Union Partner or a child of the Subscriber or the
Subscriber's spouse or Civil Union Partner. All references to the spouse of a Subscriber shall include a
Domestic Partner or Life Partner. The term child includes any of the following:

A natural child.
COC.DEF.I.11.NJ
72

A stepchild.

A legally adopted child.

A child placed for adoption.

A child for whom legal guardianship has been awarded to the Subscriber or the Subscriber's
spouse.
To be eligible for coverage under the Policy, a Dependent must reside within the United States.
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 an unmarried dependent child age 26 or older who is or becomes disabled
and dependent upon the Subscriber.
If we are not notified that a child no longer meets the above requirements, the Subscriber must reimburse
us for any Benefits that we pay for a child at a time when the child did not satisfy these conditions.
A Dependent also includes a child for whom health care coverage is required through a Qualified Medical
Child Support Order or other court or administrative order. The Enrolling Group is responsible for
determining if an order meets the criteria of a Qualified Medical Child Support Order.
A Dependent does not include anyone who is also enrolled as a Subscriber. No one can be a Dependent
of more than one Subscriber.
When Coverage Ends.
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 your geographic area. The fact that a
Hospital is a Network Hospital does not mean that it is a Designated Facility.
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 your geographic area.
The fact that a Physician is a Network Physician does not mean that he or she is a Designated Physician.
Developmental Disability - a severe, chronic disability of a person which:

is attributable to a mental or physical impairment or combination of mental or physical impairments;

is manifested before age 22;

is likely to continue indefinitely;

results in substantial functional limitations in three or more of the following areas of major life
activity, that is, self-care, receptive and expressive language, learning, mobility, self-direction and
capacity for independent living or economic self-sufficiency; and

reflects the need for a combination and sequence of special inter-disciplinary or generic care,
treatment or other services which are of lifelong or extended duration and are individually planned
and coordinated. Developmental disability includes but is not limited to severe disabilities
attributable to mental retardation, autism, cerebral palsy, epilepsy, spina-bifida and other
neurological impairments where the above criteria are met.
Domestic Partner - a person of the opposite or same sex with whom the Subscriber has established a
Domestic Partnership under either statutory or common law.
COC.DEF.I.11.NJ
73
Domestic Partnership - a relationship between a Subscriber and one other person of the opposite or
same sex. All of the following requirements apply to both persons:

They must not be related by blood or a degree of closeness that would prohibit marriage in the law
of the state in which they reside.

They must not be currently married to, or a Domestic Partner of, another person under either
statutory or common law.

They must share the same permanent residence and the common necessities of life.

They must be financially interdependent.
As of February 19, 2007, only those persons age 62 or older may enter into a Domestic Partnership in the
State of New Jersey. Domestic Partnerships registered prior to February 19, 2007 may continue to
renew/purchase coverage.
Same sex Domestic Partners who entered into a Domestic Partnership prior to February 19, 2007 have
the right to enter into a Civil Union pursuant to New Jersey Law. Entry into a Civil Union will terminate the
Domestic Partnership.
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.

Is not implantable within the body.
Eligible Expenses - for Covered Health Services, incurred while the 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 in accordance with our reimbursement policy guidelines. We develop
our reimbursement policy guidelines following evaluation and validation of all provider billings in
accordance with one or more of the following methodologies:

(CMS).



source or determination that we accept.
For Network Providers, Eligible Expenses are based upon the contracted rate between us and the
Network provider. For non-Network providers, Eligible Expenses are based upon either the Prevailing
Health Care System (PHCS) fees or the Maximum Non-Network Reimbursement Program (MNRP),
depending upon what the Enrolling Group has purchased. The provision that applies to your plan (PHCS
or MNRP) is outlined in your Schedule of Benefits under the heading Eligible Expenses.
COC.DEF.I.11.NJ
74
because the amount paid for Eligible Expenses may be a lesser amount
Eligible Person - an employee of the Enrolling Group or other person whose connection with the
Enrolling Group meets the eligibility requirements specified in both the application and the Policy. An
Eligible Person must reside within the United States.
Emergency - a medical condition manifesting itself by acute symptoms of sufficient severity including, but
not limited to severe pain, psychiatric disturbances and/or symptoms of substance abuse such that a
prudent lay person, who possesses an average knowledge of health and medicine, could reasonably
expect the absence of immediate attention to result in:

placing the health of the individual (or with respect to a pregnant woman, the health of the woman
or her unborn child) in serious jeopardy; or

serious impairment to bodily functions; or

serious dysfunction of a bodily organ or part.
With respect to a pregnant woman who is having contractions, an Emergency exists where there is
inadequate time to effect a safe transfer to another Hospital before delivery or if the transfer may pose a
threat to the health or safety of the woman or the unborn child.
Emergency Health Services - health care services and supplies, including a medical screening exam,
necessary for the evaluation and treatment of an Emergency.
Health services are considered to be for the treatment of an Emergency as long as transfer of the
Covered Person to a Network provider is precluded because of risk to the Covered Person's health or
because transfer would be unreasonable, given the distance involved in the transfer or the nature of the
medical condition.
Enrolled Dependent - a Dependent who is properly enrolled under the Policy.
Enrolling Group - the employer, or other defined or otherwise legally established group, to whom the
Policy is issued.
Experimental or Investigational Service(s) - medical, surgical, diagnostic, psychiatric, mental health,
substance use disorders or other health care services, technologies, supplies, treatments, procedures,
drug therapies, medications or devices that, at the time we make a determination regarding coverage in a
particular case, are determined to be any of the following:

Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the
proposed use and not identified in the American Hospital Formulary Service or the United States
Pharmacopoeia Dispensing Information as appropriate for the proposed use; except that coverage
is provided for a drug which has been prescribed for a treatment for which the drug has not been
approved by the FDA provided the drug is recognized for the specific treatment for which the drug
has been prescribed in one of the following 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 Pharmacists' American Hospital Formulary Service Drug Information (AHES-DI) or, it is
recommended by a clinical study or review article in a major peer reviewed professional journal.
However, there is no coverage for any drug which the FDA has determined to be contraindicated
for the specific treatment for which the drug has been prescribed.
COC.DEF.I.11.NJ
75

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 1, 2 or 3 clinical trial set
forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight.
Exceptions:

Clinical trials for which Benefits are available as described under Clinical Trials in Section 1:

Life -Threatening Sickness or Condition. If you have a life-threatening Sickness or condition (one
that is likely to cause death within one year of the request for treatment) we may, in our discretion,
consider an otherwise 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.
Family Cost Share - The New Jersey Early Intervention System (NJEIS) family cost share is a
progressive co-payment per hour of direct services provided in accordance with an Individualized Family
Service Plan (IFSP) that is based upon family size and NJEIS determined income along the federal
poverty level guidelines.
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 - a program or organization authorized by law to provide health care services in
the home or is Medicare certified.
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.
Individualized Family Service Plan (IFSP) - The IFSP is both a plan and a process. The plan is a
written document that identifies the outcomes, services and supports needed for the child and family. The
process is ongoing assessment to gather, share, and exchange information between the family and the
early intervention practitioners to help parents make informed choices about early intervention services
and other needed services for the child and family.
Infertility - the disease or condition that results in the abnormal function of the reproductive system such
that a person is not able to do one of the following:

Impregnate another person.

Conceive after one year of unprotected intercourse if the female partner is under 35 years of age.

Conceive after six months of unprotected intercourse if the female partner is 35 years of age or
older or one of the partners is considered medically sterile.

Carry a pregnancy to live birth.
Inherited Metabolic Disease - a disease caused by an inherited abnormality of body chemistry.
COC.DEF.I.11.NJ
76
Initial Enrollment Period - the initial period of time during which Eligible Persons may enroll themselves
and their Dependents under the Policy.
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.
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 use disorder
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.
Low Protein Modified Food Product - a food product that is specifically formulated to have less than
one gram of protein per serving and is intended to be used under the direction of a Physician for the
dietary treatment of an Inherited Metabolic Disease, but does not include a natural food that is naturally
low in protein.
Manipulative Treatment - the therapeutic application of chiropractic and/or osteopathic manipulative
treatment with or without ancillary physiologic treatment and/or rehabilitative methods rendered to
restore/improve motion, reduce pain and improve function in the management of an identifiable
neuromusculoskeletal condition.
Medical Food - a food that is intended for the dietary treatment of a disease or condition for which
nutritional requirements are established by medical evaluation and is formulated to be consumed or
administered enterally under the direction of a Physician.
Medically Necessary - health care services provided for the purpose of preventing, evaluating,
diagnosing or treating a Sickness, Injury, Mental Illness, substance use disorder, condition, disease or its
symptoms, that are all of the following as determined by us or our designee, within our sole discretion.

In accordance with Generally Accepted Standards of Medical Practice.

Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered
effective for your Sickness, Injury, Mental Illness, substance use disorder, disease or its symptoms.

Not mainly for your convenience or that of your doctor or other health care provider.

Not more costly than an 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.
COC.DEF.I.11.NJ
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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. The decision to
apply Physician specialty society recommendations, the choice of expert and the determination of when
to use any such expert opinion, shall be within our sole discretion.
With respect to Pharmaceutical Products, no prescribed drug shall be excluded on the basis that the drug
has not been approved by the United States Food and Drug Administration (USFDA) for the use for which
the drug has been prescribed, if such drug is recognized as medically appropriate for the specific
treatment for which it has been prescribed by the American Hospital Formulary Service Drug Information,
the United States Pharmacopoeia Drug Information or a clinical study or review article in a major peer
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 Use Disorder Designee - the organization or individual, designated by us,
that provides or arranges Mental Health Services, Neurobiological Disorder - Autism Spectrum Disorder
Services and Substance Use Disorder Services for which Benefits are available under the Policy.
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 the Policy. Mental Illness includes Biologically Based Mental Illnesses.
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 by way of their participation in the Shared Savings Program. 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 - for Benefit plans that have a Network Benefit level, this is the description of how
Benefits are paid for Covered Health Services provided by Network providers. Refer to the Schedule of
Benefits to determine whether or not your Benefit plan offers Network Benefits and for details about how
Network Benefits apply.
New Jersey Early Intervention System (NJEIS) - The New Jersey Early Intervention System (NJEIS),
under the Division of Family Health Services, implements New Jersey's statewide system of services for
infants and toddlers, birth to age three, with developmental delays or disabilities, and their families. The
Department of Health and Senior Services is appointed by the Governor as the state lead agency for the
NJEIS.
COC.DEF.I.11.NJ
78
Non-Network Benefits - for Benefit plans that have a Non-Network Benefit level, this is the description of
how Benefits are paid for Covered Health Services provided by non-Network providers. Refer to the
Schedule of Benefits to determine whether or not your Benefit plan offers Non-Network Benefits and for
details about how Non-Network Benefits apply.
Open Enrollment Period - a period of time that follows the Initial Enrollment Period during which Eligible
Persons may enroll themselves and Dependents under the Policy. The Enrolling Group determines the
period of time that is the Open Enrollment Period.
Out-of-Pocket Maximum - for Benefit plans that have an Out-of-Pocket Maximum, this is the maximum
amount you pay every year. Annual Deductibles, Copayments and Coinsurance will apply to the Out-ofPocket Maximum. Refer to the Schedule of Benefits to determine whether or not your Benefit plan is
subject to an Out-of-Pocket Maximum.
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
the Policy.
Pharmaceutical Product 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 which tier a particular Pharmaceutical Product has been assigned through the Internet at
Pharmaceutical Product List Management Committee - the committee that we designate for, among
other responsibilities, classifying Pharmaceutical Products into specific tiers.
Physician - any Doctor of Medicine or Doctor of Osteopathy who is properly licensed and qualified by
law.
Please Note: Any audiologist, podiatrist, dentist, psychologist, chiropractor, chiropodist, optometrist, nurse
midwife, physical therapist, psychologist, registered professional nurse, speech-language pathologist 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 the Policy.
Policy - the entire agreement issued to the Enrolling Group that includes all of the following:

The Group Policy.

This Certificate.



Riders.

Amendments.
These documents make up the entire agreement that is issued to the Enrolling Group.
Policy Charge - the sum of the Premiums for all Subscribers and Enrolled Dependents enrolled under
the Policy.
Pregnancy - includes all of the following:
COC.DEF.I.11.NJ
79

Prenatal care.

Postnatal care.

Childbirth.

Any complications associated with Pregnancy.
Premium - the periodic fee required for each Subscriber and each Enrolled Dependent, in accordance
with the terms of the Policy.
Primary Physician - a Physician who has a majority of his or her practice in general pediatrics, internal
medicine, obstetrics/gynecology, 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.
Related Structured Behavioral Programs - services delivered by a qualified practitioner that are
comprised of multiple intervention strategies (that is, behavioral intervention packages) based upon the
principles of ABA. These packages may include but are not limited to:

activity schedules;

discrete trial instruction;

incidental teaching;

natural environment training;

picture exchange communication system;

pivotal response treatment;

script and script-fading procedures; and

self-management.
Rescission - a retroactive cancellation or discontinuance of coverage, e.g., policy void from enrollment,
or benefits previously paid that are declared void, due to fraud or intentional misrepresentation of material
fact.
Residential Treatment Facility - a facility which provides a program of effective Mental Health Services
or Substance Use Disorder 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 Use Disorder Designee.
COC.DEF.I.11.NJ
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
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
Certificate. Covered Health Services provided by a Rider may be subject to payment of additional
Premiums. Riders are effective only when signed by us and the Enrolling Group and are subject to all
conditions, limitations and exclusions of the Policy except for those that are specifically amended in the
Rider.
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 Standards of Medical
Practice, or when a Semi-private Room is not available.
Shared Savings Program - the Shared Savings Program provides access to discounts from the
provider's charges when services are rendered by those non-Network providers that participate in that
program. We will use the Shared Savings Program to pay claims when doing so will lower the amount you
are responsible to pay for the service. We do not credential the Shared Savings Program providers and
the Shared Savings Program providers are not Network providers. Accordingly, Benefits for Covered
Health Services provided by Shared Savings Program providers will be paid at the Non-Network Benefit
level (except in cases of Emergency Health Services or Network exceptions). When we use the Shared
Savings Program to pay a claim, your responsibility is limited to Coinsurance calculated on the
contractually negotiated discount rate paid to the provider, in addition to any required deductible. You will
not be balance billed for amounts that exceed this contractually negotiated discount rate.
To determine whether a provider is part of the Shared Savings Program you can call the Customer
Service number on your ID card or logon to www.myuhc.com.
Sickness - physical illness, disease or Pregnancy. The term Sickness as used in this Certificate does not
include Mental Illness or substance use disorders, regardless of the cause or origin of the Mental Illness
or substance use disorder.
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, obstetrics/gynecology, family practice or general medicine. For Mental
Health Services and Substance Use Disorder Services, any licensed clinician is considered on the same
basis as a Specialist Physician.
Subscriber - an Eligible Person who is properly enrolled under the Policy. The Subscriber is the person
(who is not a Dependent) on whose behalf the Policy is issued to the Enrolling Group.
Substance Use Disorder Services - Covered Health Services for the diagnosis and treatment of
alcoholism and substance use 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.
COC.DEF.I.11.NJ
81
Total Disability or Totally Disabled - a Subscriber's inability to perform all of the substantial and
material duties of his or her regular employment or occupation; and a Dependent's inability to perform the
normal activities of a person of like age and sex.
Transitional Care - Mental Health Services and Substance Use Disorder 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.

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.
These include:

Well-conducted randomized controlled trials. (Two or more treatments are compared to each other,
and the patient is not allowed to choose which treatment is received.)

Well-conducted cohort studies from more than one institution. (Patients who receive study
treatment are compared to a group of patients who receive standard therapy. The comparison
group must be nearly identical to the study treatment group.)
We have a process by which we compile and review clinical evidence with respect to certain health
services. From time to time, we issue medical and drug policies that describe the clinical evidence
available with respect to specific health care services. These medical and drug policies are subject to
change without prior notice. You can view these policies at www.myuhc.com.
Please note:

If you have a life-threatening Sickness or condition (one that is likely to cause death within one year
of the request for treatment) we may, in our discretion, consider an otherwise Unproven Service to
be a Covered Health Service for that Sickness or condition. Prior to such a consideration, we must
first establish that there is sufficient evidence to conclude that, albeit unproven, the service has
significant potential as an effective treatment for that Sickness or condition.

With respect to Pharmaceutical Products, no prescribed drug shall be excluded on the basis that
the drug has not been approved by the United States Food and Drug Administration (USFDA) for
the use for which the drug has been prescribed, if such drug is recognized as medically appropriate
for the specific treatment for which it has been prescribed by the American Hospital Formulary
Service Drug Information, the United States Pharmacopoeia Drug Information or a clinical study or
review article in a major peer reviewed professional journal.
Urgent Care Center - a facility that provides Covered Health Services that are non-life-threatening but
that require care by a provider within 24 hours.
COC.DEF.I.11.NJ
82
As described in this Amendment, the Certificate is modified to provide coverage for oral
chemotherapeutic agents used to kill or slow the growth of cancerous cells.
1.
The exclusion for outpatient prescription drugs in the Certificate under Section 2: Exclusions and
Limitations, Drugs is replaced with the following:
D. Drugs
1.
Prescription drug products for outpatient use that are filled by a prescription order or refill, except
for oral chemotherapeutic agents used to kill or slow the growth of cancerous cells if this Policy
does not include an Outpatient Prescription Drug Rider. This exclusion also does not apply to oral
agents for controlling blood sugar or to medications used to treat infertility for which Benefits are
provided as described under Diabetes Services and Infertility Services in Section 1: Covered
Health Services.
2.
Self-injectable medications, except as described under Diabetes Services in Section 1: Covered
Health Services. 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.
3.
4.
Services.
5.
6.
7.
ORALCHEMO.AMD.I.11.NJ
1
Health Resources and Services Administration
(HRSA) Amendment
As described in this Amendment, the Certificate is modified as stated below.
Benefits for Breast Pumps
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. These Benefits are
provided as described under Preventive Care Services in the Certificate, Section 1: Covered Health
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.
As a result of this requirement, the exclusion for supplies, equipment and similar incidental services and
supplies for personal comfort in Section 2: Exclusions and Limitations under Personal Care, Comfort or
Convenience is replaced with the following:
Personal Care, Comfort or Convenience
Supplies, equipment and similar incidental services and supplies for personal comfort. Examples include:



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.


Exercise equipment.


Hot tubs.

Humidifiers.

Jacuzzis.
AMD.HRSA.I.11.NJ
1

Mattresses.


Motorized beds.

Music devices.

Personal computers.

Pillows.


Radios.

Saunas.


Strollers.

Safety equipment.

Treadmills.


Video players.

Whirlpools.
AMD.HRSA.I.11.NJ
2
Outpatient Prescription Drug
Benefits for Prescription Drug Products
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.
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
Benefits. For a single copayment or coinsurance, the Insured may receive a Prescription Drug Product up
to the stated supply limit. We will cover up to a consecutive 90-day supply of a Prescription Drug Product,
as written by the Physician, subject to the drug manufacturer’s packaging size, or based on supply limits.
than a consecutive 31-day supply, the copayment or coinsurance that applies will reflect the number of
days dispensed.
Note: Some products are subject to additional supply limits other than day limits based on criteria that the
Company has developed, subject to its 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.
dispensing through the Internet at www.myuhc.com or by calling Customer Service at the telephone
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.
1
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.
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
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 Prescription Drug Products from a Network Pharmacy) or the
Allowable Expense (for Prescription Drug Products from a non-Network Pharmacy), less the required
Copayment or Coinsurance, and any deductible that applies.
Benefits may not be available for the Prescription Drug Product after we review the documentation
provided and we determine that the Prescription Drug Product is not a Covered Health Service or it is an
Experimental or Investigational or Unproven Service.
We may also require prior authorization for certain programs which may have specific requirements for
participation and/or activation of an enhanced level of Benefits associated with such programs. You may
access information on available programs and any applicable prior authorization, participation or
activation requirements associated with such programs through the Internet at www.myuhc.com or by
Approval Process for Prescription Drug Products that the Covered
Person wants considered at a Lower Tier copayment
The prescribing Physician must request our prior approval for a lower tier copayment for a higher tier drug
by contacting the Customer Care Department and providing all relevant information. We will respond to
the Physician by telephone within one business day after the receipt of all requested documentation from
the Physician. If we fail to respond within that time period, the request is deemed approved. The request
for approval must be based on the Physician's certification that the Prescription Drug Product is medically
necessary as defined below and the current drugs available in the lower Tiers are not effective for the
Covered Person.
A Prescription Drug Product which is not on the Prescription Drug List will be considered medically
necessary if:

It is approved by the U.S. Federal Food and Drug Administration ("FDA") or its use is supported by
one or more citations included or approved for inclusion in The American Hospital Formulary Drug
Information or the United States Pharmacopeia- Drug Information, or it is recommended by a
clinical study or review article in a major peer reviewed professional journal; and
2

The prescribing Physician states that all Prescription Drug Products on the Prescription Drug List
used to treat each disease state has been ineffective in the treatment of your disease or condition,
or all such drugs have caused or are reasonably expected to cause you adverse or harmful
reactions.
If the request is denied by telephone, we will also provide you and the Physician a written denial within 5
business days of the request. The written denial will include the clinical reason for the denial.
If you are dissatisfied with our decision, you should follow the procedures described in the Certificate for
questions, complaints and appeals. If you want to contest our decision you may apply to the Independent
Health Care Appeals Program for a review. You must make your application within 60 days of the date
you were notified of the decision. Your notification of our decision will include specific instructions as to
how you or your provider may arrange for an external appeal and will also include any forms required to
initiate the appeal.
Emergency
Prescription Drug Products dispensed at a Non-Network Pharmacy for an Emergency are payable for the
Eligible Expenses, minus the applicable Network Copayment or Coinsurance.
Extended Coverage during Total Disability
Extended Coverage for Total Disability described in the Certificate applies to Prescription Drug Products.
Pharmacy Charges for Additional Services
A pharmacy may charge you for services rendered by the pharmacy that are in addition to charges for the
Prescription Drug Product, for dispensing the drug or for prescription counseling. Services rendered by
the pharmacy for which additional charges are imposed are subject to the approval of the Board of
Pharmacy. A pharmacy must disclose to you the charges for the additional services and your out-ofpocket cost for those services prior to dispensing the Prescription Drug Product. A pharmacy may not
impose any additional charges for patient counseling or for other services required by the Board of
Pharmacy or State or federal law.
What You Must Pay
You are responsible for paying the Annual Deductible stated in the Schedule of Benefits which is attached
to your Certificate before Benefits for Prescription Drug Products under this Rider are available to you.
Benefits for Prescription Drug Products on the List of Preventive Medications are not subject to payment
of the Annual Deductible.
Benefits for Preventive Care Medications are not subject to payment of the Annual Deductible.
You are responsible for paying the applicable Copayment or Coinsurance described in the Benefit
Information table. You are not responsible for paying a Copayment or Coinsurance for Preventive Care
Medications.
The amount you pay for any of the following under this Rider will not be included in calculating any Outof-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.
3
Payment Information
Copayment
Copayment for a Prescription Drug
Product at a Network or non-Network
Pharmacy is a specific dollar amount.
For Prescription Drug Products at a retail Network
following:

Coinsurance

Product at a Network Pharmacy is a
percentage of the Prescription Drug
Charge.
The Network Pharmacy's Usual and Customary
Charge for the Prescription Drug Product.
For Prescription Drug Products from a mail order Network
following:
Product at a non-Network Pharmacy is
a percentage of the Predominant
Reimbursement Rate.


The Prescription Drug Charge for that Prescription
Drug Product.
See the Copayments or Coinsurance stated in the Benefit
Information table for amounts.
Your Copayment or Coinsurance is
determined by the tier to which the
Management Committee has assigned
a Prescription Drug Product.
You are not responsible for paying a Copayment or
Coinsurance for Preventive Care Medications.
Special Programs: We may have
certain programs in which you may
receive a reduced or increased
Copayment or Coinsurance 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
Care at the telephone number on your
ID card.
Prescription Drug Products
Prescribed by a Specialist Physician:
You may receive a reduced or
increased Copayment or Coinsurance
based on whether the Prescription Drug
Product was prescribed by a Specialist
Physician. You may access information
on which Prescription Drug Products are
subject to a reduced or increased
Copayment or Coinsurance through the
Internet at www.myuhc.com or by
5
calling Customer Care at the telephone
NOTE: The tier status of a Prescription
Drug Product can change periodically,
generally quarterly but no more than six
times per calendar year, based on the
Management Committee's periodic
tiering decisions. When that occurs, you
may pay more or less for a Prescription
Drug Product, depending on its tier
assignment. Please access
www.myuhc.com through the Internet or
call Customer Care at the telephone
number on your ID card for the most upto-date tier status.
6
Benefit Information

90-day supply of a Specialty
subject to the drug
When a Specialty Prescription Drug
Product is packaged or designed to
deliver in a manner that provides more
than a consecutive 31-day supply, the
dispensed.
Supply limits apply to Specialty
Prescription Drug Products obtained at
a Network Pharmacy, a non-Network
Pharmacy, a mail order Network
Pharmacy or a Designated Specialty
Pharmacy.
your ID card.
Committee has assigned the Specialty Prescription Drug
Product. All Specialty Prescription Drug Products on the
Prescription Drug List are assigned to Tier-1, Tier-2 or Tier3. Please access www.myuhc.com through the Internet or
call Customer Care at the telephone number on your ID
card to determine tier status.
Network Pharmacy
Non-Network Pharmacy
Prescription Drugs from a Retail
Network Pharmacy

7

status.
When a Prescription Drug Product is
packaged or designed to deliver in a
manner that provides more than a
consecutive 31-day supply, the
dispensed.
Prescription Drugs from a Retail NonNetwork Pharmacy


status.
8
your ID card.
Prescription Drug Products from a
Mail Order Network Pharmacy
The following supply limits apply:

consecutive 90-day supply of a
subject to the drug
based on supply limits. These
supply limits do not apply to
Specialty Prescription Drug
Products. Specialty Prescription
Drug Products from a mail order
Network Pharmacy are subject to
the supply limits stated above
under the heading Specialty
status.
For up to a 90-day supply, we pay:
To maximize your Benefit, ask your
Physician to write your Prescription
Order or Refill for a 90-day supply, with
refills when appropriate. You will be
charged a mail order Copayment or
Coinsurance for any Prescription Orders
or Refills sent to the mail order
pharmacy regardless of the number-ofdays' supply written on the Prescription
Order or Refill. Be sure your Physician
writes your Prescription Order or Refill
for a 90-day supply, not a 30-day supply
with three refills.
your ID card.
9
This Rider to the Policy is issued to the Enrolling Group and provides Benefits for Prescription Drug
Products.
Because this Rider is part of 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 either the Certificate of Coverage (Certificate) in Section 9: Defined Terms or in this Rider in
Section 3: Defined Terms.
Insurance Company. When we use the words "you" and "your" we are referring to people who are
Covered Persons, as the term is defined in the Certificate in Section 9: Defined Terms.
NOTE: The Coordination of Benefits provision in the Certificate in Section 7: Coordination of Benefits
applies to Prescription Drug Products covered through this Rider. Benefits for Prescription Drug Products
will be coordinated with those of any other health plan in the same manner as Benefits for Covered
Health Services described in the Certificate.
RDR.RX.PLS.I.11.NJ
11
Introduction
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. Economic factors are
considered when two or more drugs are equivalent in terms of safety, effectiveness and clinical outcome.
Please refer to the Outpatient Prescription Drug Schedule of Benefits for more information concerning
Prior Authorization requirements.
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.
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.
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 the Certificate 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 and/or Coinsurance, and any deductible that
applies.
Submit your claim to the Pharmacy Benefit Manager claims address noted on your ID card.
Designated Specialty Pharmacies
If you require certain Specialty Prescription Drug Products for disease states such as:
RDR.RX.PLS.I.11.NJ
12

Hepatitis C

Multiple Sclerosis

Rheumatologic and related conditions (Rheumatoid Arthritis, Psoriatic Arthritis, Ankylosing
Spondylitis, Juvenile Rheumatoid Arthritis, Psoriasis)

Growth Hormone

Anemia, neutropenia, thrombocytopenia

Infertility

HIV/AIDS

Transplant

Oral Oncology

Pulmonary Arterial Hypertension

Osteoporosis

Cystic Fibrosis

Gaucher's Disease

Iron Overload

Endocrine disorders/Neurologic disorders such as infantile spasms

Hemophilia

Enzyme Deficiencies/Liposomal Storage Disorders
we may direct you to a Designated Specialty Pharmacy with whom we have an arrangement to provide
those Specialty Prescription Drug Products.
If you are directed to a Designated Specialty Pharmacy and you choose not to obtain your Prescription
Drug Product from a Designated Specialty Pharmacy, you will be subject to the non-Network Benefit for
that Prescription Drug Product.
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.
We may receive rebates for certain drugs included on the Prescription Drug List. We do not pass these
rebates on to you, nor are they applied to the combined medical and pharmacy Annual Deductible stated
in the Schedule of Benefits attached to your Certificate or taken into account in determining your
Copayments and/or Coinsurance.
We, and a number of our affiliated entities, conduct business with various pharmaceutical manufacturers
separate and apart from this Outpatient Prescription Drug Rider. Such business may include, but is not
limited to, data collection, consulting, educational grants and research. Amounts received from
RDR.RX.PLS.I.11.NJ
13
pharmaceutical manufacturers pursuant to such arrangements are not related to this Outpatient
Prescription Drug Rider. 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.
Special Programs
You may qualify for certain programs in which you may receive an enhanced benefit based on your
adherence/compliance with medication or treatment regimens, and/or participation in health management
programs.
For certain qualifying medications, you may receive a $20 savings on your standard coinsurance if you
are taking the medication regularly and you refill your medication within 30 days of the date you are
scheduled to run out of medication. If you don't refill your medication within 30 days of the date you are
scheduled to run out of medication, you will pay your standard copayment. You may access further
information on these programs and which medications are included through the internet at
www.myuhc.com or by calling Customer Care at the telephone number on your ID Card. Please note this
program is subject to change without notice.
RDR.RX.PLS.I.11.NJ
14
Outpatient Prescription Drug Rider Table of Contents
Section 1: Benefits for Prescription Drug Products..............................16
Section 2: Exclusions ...............................................................................18
RDR.RX.PLS.I.11.NJ
15
Section 1: Benefits for Prescription Drug Products
Pharmacy and are subject to Copayments and/or Coinsurance or other payments that vary depending on
which of the tiers of the Prescription Drug List the Prescription Drug Product is listed. Refer to the
Outpatient Prescription Drug Schedule of Benefits for applicable Copayments and/or Coinsurance
requirements.
Benefits are provided for Specialty Prescription Drug Products.
If you require Specialty Prescription Drug Products, we may direct you to a Designated Specialty
Pharmacy with whom we have an arrangement to provide those Specialty Prescription Drug Products.
If you are directed to a Designated Specialty Pharmacy and you choose not to obtain your Specialty
Prescription Drug Product from a Designated Specialty Pharmacy, you will be subject to the non-Network
Benefit for that Specialty Prescription Drug Product.
Please see Section 3: Defined Terms for a full description of Specialty Prescription Drug Product and
Designated Specialty Pharmacy.
Refer to the Outpatient Prescription Drug Schedule of Benefits for details on Specialty Prescription Drug
Product supply limits.
Prescription Drugs from a Retail Network Pharmacy
Benefits are provided for Prescription Drug Products dispensed by a retail Network Pharmacy.
Refer to the Outpatient Prescription Drug 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 your Certificate, Section 5: How to File a Claim. We will not reimburse you for the difference
between the Allowable Expense 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 Outpatient Prescription Drug Schedule of Benefits for details on retail non-Network Pharmacy
supply limits.
Prescription Drug Products from a Mail Order Network Pharmacy
Benefits are provided for certain Prescription Drug Products dispensed by a mail order Network
Pharmacy.
Refer to the Outpatient Prescription Drug Schedule of Benefits for details on mail order Network
Pharmacy supply limits, Copayments or Coinsurance.
Supply Limits
RDR.RX.PLS.I.11.NJ
16
Benefits. For a single Copayment or Coinsurance, the Insured may receive a Prescription Drug Product
up to the stated supply limit. We will cover up to a consecutive 90-day supply of a Prescription Drug
Product, as written by the Physician, subject to the drug manufacturer’s packaging size, or based on
supply limits.
than a consecutive 31-day supply, the Copayment or Coinsurance that applies will reflect the number of
days dispensed.
NOTE: Some products are subject to additional supply limits other than day limits based on criteria that
the Company has developed, subject to its 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.
dispensing through the Internet at www.myuhc.com or by calling Customer Care at the telephone number
on your ID card.
RDR.RX.PLS.I.11.NJ
17
Section 2: Exclusions
Exclusions from coverage listed in the Certificate apply also to this Rider, except that any preexisting
condition exclusion in the Certificate is not applicable to this Rider. 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.
2.
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. No prescribed drug shall be excluded on the basis that the drug has
not been approved by the United States Food and Drug Administration (USFDA) for which the drug
has been prescribed, if such drug is recognized as medically appropriate for the specific treatment
for which it has been prescribed by the American Hospital Formulary Service Drug Information, the
United States Pharmacopoeia Drug Information or a clinical study or review article in a major peer
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.
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. The failure of a self-employed person, limited liability partnership, limited liability company
or partnership to elect to obtain worker's compensation coverage for the self-employed person, the
limited liability partners, the limited liability company members or the partners shall not affect
benefits available under this rider.
8.
Any product dispensed for the purpose of appetite suppression or weight loss.
9.
A Pharmaceutical Product for which Benefits are provided in your Certificate. This exclusion does
not apply to Depo Provera and other injectable 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 of Prescription Drug Products.
13.
Medications used for cosmetic purposes except for coverage for newborn children including the
necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.
RDR.RX.PLS.I.11.NJ
18
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.
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 for smoking cessation.
17.
Compounded drugs that do not contain at least one ingredient that has been approved by the U.S.
Food and Drug Administration (FDA) and requires a Prescription Order or Refill. Compounded
drugs that are available as a similar commercially available Prescription Drug Product.
(Compounded drugs that contain at least one ingredient that requires a Prescription Order or Refill
are assigned to Tier-3.)
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. Prescription Drug Products that are available in over-the-counter
form or comprised of components that are available in over-the-counter form or equivalent unless
the prescribing health care provider certifies the medical necessity of the drug. 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.
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.
20.
Growth hormone for children with familial short stature (short stature based upon heredity and not
caused by a diagnosed medical condition).
21.
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 as
required by state mandate.
RDR.RX.PLS.I.11.NJ
19
Brand-name - a Prescription Drug Product which is manufactured and marketed under a trademark or
name by a specific drug manufacturer.
Chemically Equivalent - when Prescription Drug Products contain the same active ingredient.
Designated Specialty Pharmacy - a pharmacy that has entered into an agreement with us or with an
organization contracting on our behalf, to provide specific Prescription Drug Products, including, but not
limited to, Specialty Prescription Drug Products. The fact that a pharmacy is a Network Pharmacy does
not mean that it is a Designated Specialty Pharmacy.
Generic - a Prescription Drug Product that is Chemically Equivalent to a Brand-name drug.
Infertility - failure to achieve a Pregnancy after a year of regular unprotected intercourse if the woman is
under age 35, or after six months if the woman is over age 35. In addition, in order to be eligible for
Benefits, the Covered Person must also:

Be under age 44, if female.

Have infertility that is not related to voluntary sterilization or failed reversal of voluntary sterilization.
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.

six months following date the Prescription Drug Product or new dosage form is approved by the
U.S. Food and Drug Administration.
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
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:
RDR.RX.PLS.I.11.NJ
20

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; and

glucose monitors.
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 and that are
payable at 100% of the cost (without application of any Copayment, Coinsurance, Annual Deductible,
Annual Drug Deductible or Specialty Prescription Drug Product Annual Deductible) as required by
applicable law under any of the following:



You may determine whether a drug is a Preventive Care Medication through the internet at
Specialty Prescription Drug Product - Prescription Drug Products that are generally high cost, selfadministered biotechnology drugs used to treat patients with certain illnesses. You may access a
complete list of Specialty Prescription 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.
RDR.RX.PLS.I.11.NJ
21
As described in this addendum, Benefits for oral chemotherapeutic agents are modified in the Outpatient
Prescription Drug Rider and Outpatient Prescription Drug Schedule of Benefits as stated below.
Because this addendum is part of a legal document (the group Policy), we want to give you information
We have defined these words in the Certificate of Coverage (Certificate) in Section 9: Defined Terms and
in the Outpatient Prescription Drug Rider.
Benefits for Oral Chemotherapeutic Agents
Oral chemotherapeutic agent Prescription Drug Products from a retail or mail order Network Pharmacy
are provided at 100% of the Prescription Drug Charge (without application of any Copayment,
Coinsurance, Annual Deductible or Annual Drug Deductible, as applicable) per Prescription Order or
Refill, regardless of tier placement. This includes oral chemotherapeutic agents that are Specialty
RXADD_ORALCHEMO.I.0711NJ
1
Act (PPACA)
IMPORTANT NOTICE: If you have a dependent child whose coverage ended or who was denied
coverage (or was not eligible for coverage) because dependent coverage of children was not available up
to age 26, you may have the right to enroll that dependent under a special dependent child enrollment
period. This right applies as of the first day of the first plan year beginning on or after September 23, 2010
and your employer (or enrolling group) must provide you with at least a 30 day enrollment period. If you
are adding a dependent child during this special enrollment period and have a choice of coverage options
under the plan, you will be allowed to change options. This child special open enrollment may coincide
with your annual open enrollment, if you have one. Please contact your employer or group plan
administrator for more information.
IMPORTANT NOTICE: If coverage or benefits for you or a dependent ended due to reaching a lifetime
limit, be advised that a lifetime limit on the dollar value of benefits no longer applies. If you are covered
under the plan, you are once again eligible for benefits. Additionally, if you are not enrolled in the plan, but
are still eligible for coverage, then you will have a 30 day opportunity to request enrollment. This 30 day
enrollment opportunity will begin no later than the first day of the first plan year beginning on or after
September 23, 2010. This 30 day enrollment period may coincide with your annual open enrollment, if
you have one. Please contact your employer or group health plan administrator for more information.
I
There are changes in Federal law which may impact coverage and Benefits stated in the Certificate of
Coverage (Certificate) and Schedule of Benefits. A summary of those changes and the dates the changes
are effective appear below.
Patient Protection and Affordable Care Act (PPACA)
Effective for policies that are new or renewing on or after September 23, 2010, the requirements listed
below apply.

Lifetime limits on the dollar amount of essential benefits available to you under the terms of your
plan are no longer permitted. Essential benefits include the following:
Ambulatory patient services; emergency services, hospitalization; maternity and newborn care,
mental health and substance use disorder services (including behavioral health treatment);
prescription drugs; rehabilitative and habilitative services and devices; laboratory services;
preventive and wellness services and chronic disease management; and pediatric services,
including oral and vision care.

enrolling group will provide a 30 day enrollment period for those individuals who are still eligible
under the plan's eligibility terms but whose coverage ended by reason of reaching a lifetime limit on
the dollar value of all benefits.

Essential benefits for plan years beginning prior to January 1, 2014 can only be subject to
restricted annual limits. Restricted annual limits for each person covered under the plan may be no
less than the following:

2011, $750,000.

2012, $1,250,000.

For plan or policy years beginning on or after September 23, 2012 but before January 1,
2014, $2,000,000.

Any pre-existing condition exclusions (including denial of benefits or coverage) will not apply to
covered persons under the age of 19.

Coverage for enrolled dependent children is no longer conditioned upon full-time student status or
other dependency requirements and will remain in place until the child's 26th birthday. If you have
a grandfathered plan, the enrolling group is not required to extend coverage to age 26 if the child is
eligible to enroll in an eligible employer-sponsored health plan (as defined by law). Under the
PPACA a plan generally is "grandfathered" if it was in effect on March 23, 2010 and there are no
substantial changes in the benefit design as described in the Interim Final Rule on Grandfathered
Health Plans.
enrolling group will provide a 30 day dependent child special open enrollment period for dependent
children who are not currently enrolled under the policy and who have not yet reached age 26.
During this dependent child special open enrollment period, subscribers who are adding a
dependent child and who have a choice of coverage options will be allowed to change options.

If your plan includes coverage for enrolled dependent children beyond the age of 26, which is
conditioned upon full-time student status, the following applies:
II
Coverage for enrolled dependent children who are required to maintain full-time student status in
order to continue eligibility under the policy is subject to the statute known as Michelle's Law. This
law amends ERISA, the Public Health Service Act, and the Internal Revenue Code and requires
group health plans, which provide coverage for dependent children who are post-secondary school
students, to continue such coverage if the student loses the required student status because he or
she must take a medically necessary leave of absence from studies due to a serious illness or
Injury.



If you do not have a grandfathered plan, in-network benefits for preventive care services described
below will be paid at 100%, and not subject to any deductible, coinsurance or copayment. If you
have pharmacy benefit coverage, your plan may also be required to cover preventive care
medications that are obtained at a network pharmacy at 100%, and not subject to any deductible,
coinsurance or copayment, as required by applicable law under any of the following:



screenings provided for in the comprehensive guidelines supported by the Health Resources
and Services Administration.

Retroactive rescission of coverage under the policy is permitted, with 30 days advance written
notice, only in the following two circumstances:

The individual performs an act, practice or omission that constitutes fraud.

The individual makes an intentional misrepresentation of a material fact.
Other changes provided for under the PPACA do not impact your plan because your plan already
contains these benefits. These include:

Direct access to OB/GYN care without a referral or authorization requirement.

The ability to designate a pediatrician as a primary care physician (PCP) if your plan requires
a PCP designation.

Prior authorization is not required before you receive services in the emergency department
of a hospital.
If you seek emergency care from out-of-network providers in the emergency department of a
hospital your cost sharing obligations (copayments/coinsurance) will be the same as would
be applied to care received from in-network providers.
Some Important Information about Appeal and External Review Rights under
PPACA
If you are enrolled in a non-grandfathered plan with an effective date or plan year anniversary on or after
September 23, 2010, the Patient Protection and Affordable Care Act of 2010 (PPACA), as amended, sets
forth new and additional internal appeal and external review rights beyond those that some plans may
have previously offered. Also, certain grandfathered plans are complying with the additional internal
appeal and external review rights provisions on a voluntary basis. Please refer to your benefit plan
documents, including amendments and notices, or speak with your employer or UnitedHealthcare for
III
more information on the appeal rights available to you. (Also, please refer to the Claims and Appeal
Notice section of this document.)
What if I receive a denial, and need help understanding it? Please call UnitedHealthcare at the
number listed on the back of your health plan ID card.
What if I don't agree with the denial? You have a right to appeal any decision to not pay for an item or
service.
How do I file an appeal? The initial denial letter or Explanation of Benefits that you receive from
UnitedHealthcare will give you the information and the timeframe to file an appeal.
What if my situation is urgent? If your situation is urgent, your review will be conducted as quickly as
possible. If you believe your situation is urgent, you may request an expedited review, and, if applicable,
file an external review at the same time. For help call UnitedHealthcare at the number listed on the back
of your health plan ID card.
Generally, an urgent situation is when your health may be in serious jeopardy. Or when, in the opinion of
your doctor, you may be experiencing severe pain that cannot be adequately controlled while you wait for
a decision on your appeal.
Who may file an appeal? Any member or someone that member names to act as an authorized
representative may file an appeal. For help call UnitedHealthcare at the number listed on the back of your
health plan ID card.
Can I provide additional information about my claim? Yes, you may give us additional information
supporting your claim. Send the information to the address provided in the initial denial letter or
Explanation of Benefits.
Can I request copies of information relating to my claim? Yes. There is no cost to you for these
copies. Send your request to the address provided in the initial denial letter or Explanation of Benefits.
What happens if I don't agree with the outcome of my appeal? If you appeal, we will review our
decision. We will also send you our written decision within the time allowed. If you do not agree with the
decision, you may be able to request an external review of your claim by an independent third party. They
will review the denial and issue a final decision.
If I need additional help, what should I do? For questions on your appeal rights, you may call
UnitedHealthcare at the number listed on the back of your health plan ID card. You may also contact the
support groups listed below.
Are verbal translation services available to me during an appeal? Yes. Contact UnitedHealthcare at
the number listed on the back of your health plan ID card. Ask for verbal translation services for your
questions.
Is there other help available to me? For questions about appeal rights, an unfavorable benefit decision,
or for help, you may also contact the Employee Benefits Security Administration at 1-866-444-EBSA
(3272). Your state consumer assistance program may also be able to help you.
For information on appeals and other PPACA regulations, visit www.healthcare.gov.
Mental Health/Substance Use Disorder Parity
Effective for Policies that are new or renewing on or after July 1, 2010, Benefits are subject to final
regulations supporting the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Benefits for
mental health conditions and substance use disorder conditions that are Covered Health Services under
the Policy must be treated in the same manner and provided at the same level as Covered Health
Services for the treatment of other Sickness or Injury. Benefits for Mental Health Services and Substance
Use Disorder Services are not subject to any annual maximum benefit limit (including any day, visit or
dollar limit).
IV
MHPAEA requires that the financial requirements for coinsurance and copayments for mental health and
substance use disorder conditions must be no more restrictive than those coinsurance and copayment
requirements for substantially all medical/surgical benefits. MHPAEA requires specific testing to be
applied to classifications of benefits to determine the impact of these financial requirements on mental
health and substance use disorder benefits. Based upon the results of that testing, it is possible that
coinsurance or copayments that apply to mental health conditions and substance use disorder conditions
in your benefit plan may be reduced.
V
As required by the Women's Health and Cancer Rights Act of 1998, Benefits under the Policy are
provided for mastectomy, including reconstruction and surgery to achieve symmetry between the breasts,
prostheses, and complications resulting from a mastectomy (including lymphedema).
If you are receiving Benefits in connection with a mastectomy, Benefits are also provided for the following
Covered Health Services, as you determine appropriate with your attending Physician:

All stages of reconstruction of the breast on which the mastectomy was performed;

Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

Prostheses and treatment of physical complications of the mastectomy, including lymphedema.
The amount you must pay for such Covered Health Services (including Copayments, Coinsurance and
any Annual Deductible) are the same as are required for any other Covered Health Service. Limitations
on Benefits are the same as for any other Covered Health Service.
Protection Act
Under Federal law, group health plans and health insurance issuers offering group health insurance
coverage generally may not restrict Benefits for any Hospital length of stay in connection with childbirth
for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours
following a delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the
attending provider (e.g. your Physician, nurse midwife, or physician assistant), after consultation with the
mother, discharges the mother or newborn earlier.
Also, under Federal law, plans and issuers may not set the level of Benefits or out-of-pocket costs so that
any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or
newborn than any earlier portion of the stay.
In addition, a plan or issuer may not, under Federal law, require that a Physician or other health care
provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to
use certain providers or facilities, or to reduce your out-ofpocket costs, you may be required to obtain
precertification. For information on precertification, contact your issuer.
VI
This Notice is provided to you in order to describe our responsibilities under Federal law for
making benefit determinations and your right to appeal adverse benefit determinations. To the
extent that state law provides you with more generous timelines or opportunities for appeal, those
rights also apply to you. Please refer to your benefit documents for information about your rights
under state law.
Benefit Determinations
Post-service Claims
received. If your post-service claim is denied, you will receive a written notice from us within 30 days of
receipt of the claim, as long as all needed information was provided with the claim. We will notify you
within this 30 day period if additional information is needed to process the claim, and may request a one
time extension not longer than 15 days and pend your claim until all information is received.
Once notified of the extension, you then have 45 days to provide this information. If all of the needed
information is received within the 45-day time frame, and the claim is denied, we will notify you of the
denial within 15 days after the information is received. If you don't provide the needed information within
the 45-day period, your claim will be denied.
If you have prescription drug Benefits and are asked to pay the full cost of a prescription when you fill it at
a retail or mail-order pharmacy, and if you believe that it should have been paid under the Policy, you
may submit a claim for reimbursement in accordance with the applicable claim filing procedures. If you
pay a Copayment and believe that the amount of the Copayment was incorrect, you also may submit a
claim for reimbursement in accordance with the applicable claim filing procedures. When you have filed a
claim, your claim will be treated under the same procedures for post-service group health plan claims as
described in this section.
Pre-service requests for Benefits are those requests that require notification or approval prior to receiving
medical care. If you have a pre-service request for Benefits, and it was submitted properly with all needed
information, you will receive written notice of the decision from us within 15 days of receipt of the request.
If you filed a pre-service request for Benefits improperly, we will notify you of the improper filing and how
to correct it within five days after the pre-service request for Benefits was received. If additional
information is needed to process the pre-service request, we will notify you of the information needed
within 15 days after it was received, and may request a one time extension not longer than 15 days and
pend your request until all information is received. Once notified of the extension you then have 45 days
to provide this information. If all of the needed information is received within the 45-day time frame, we
will notify you of the determination within 15 days after the information is received. If you don't provide the
needed information within the 45-day period, your request for Benefits will be denied. A denial notice will
explain the reason for denial, refer to the part of the plan on which the denial is based, and provide the
appeal procedures.
If you have prescription drug Benefits and a retail or mail order pharmacy fails to fill a prescription that
you have presented, you may file a pre-service health request for Benefits in accordance with the
applicable claim filing procedure. When you have filed a request for Benefits, your request will be treated
under the same procedures for pre-service group health plan requests for Benefits as described in this
section.
VII
Urgent Requests for Benefits that Require Immediate Attention
Urgent requests for Benefits are those that require notification or a benefit determination prior to receiving
medical care, where a delay in treatment could seriously jeopardize your life or health, or the ability to
regain maximum function or, in the opinion of a Physician with knowledge of your medical condition, could
cause severe pain. In these situations, you will receive notice of the benefit determination in writing or
electronically within 72 hours after we receive all necessary information, taking into account the
seriousness of your condition.
If you filed an urgent request for Benefits improperly, we will notify you of the improper filing and how to
correct it within 24 hours after the urgent request was received. If additional information is needed to
process the request, we will notify you of the information needed within 24 hours after the request was
received. You then have 48 hours to provide the requested information.
You will be notified of a benefit determination no later than 48 hours after:

Our receipt of the requested information; or

The end of the 48-hour period within which you were to provide the additional information, if the
information is not received within that time.
Concurrent Care Claims
If an on-going course of treatment was previously approved for a specific period of time or number of
treatments, and your request to extend the treatment is an urgent request for Benefits as defined above,
your request will be decided within 24 hours, provided your request is made at least 24 hours prior to the
end of the approved treatment. We will make a determination on your request for the extended treatment
within 24 hours from receipt of your request.
If your request for extended treatment is not made at least 24 hours prior to the end of the approved
treatment, the request will be treated as an urgent request for Benefits and decided according to the
timeframes described above. If an on-going course of treatment was previously approved for a specific
period of time or number of treatments, and you request to extend treatment in a non-urgent
circumstance, your request will be considered a new request and decided according to post-service or
pre-service timeframes, whichever applies.
Questions or Concerns about Benefit Determinations
If you have a question or concern about a benefit determination, you may informally contact our Customer
Care department before requesting a formal appeal. If the Customer Care representative cannot resolve
the issue to your satisfaction over the phone, you may submit your question in writing. However, if you
are not satisfied with a benefit determination as described above, you may appeal it as described below,
without first informally contacting a Customer Care representative. If you first informally contact our
Customer Care department and later wish to request a formal appeal in writing, you should again contact
Customer Care and request an appeal. If you request a formal appeal, a Customer Care representative
will provide you with the appropriate address.
If you are appealing an urgent claim denial, please refer to Urgent Appeals that Require Immediate Action
below and contact our Customer Care department immediately.
If you disagree with a pre-service request for Benefits determination or post-service claim determination
or a rescission of coverage determination after following the above steps, you can contact us in writing to
formally request an appeal.
VIII
Your request should include:





Your first appeal request must be submitted to us within 180 days after you receive the claim denial.
Appeal Process
and free of charge, you have the right to reasonable access to and copies of all documents, records, and

conducted and you will be notified of the decision within 15 days from receipt of a request for
appeal of a denied request for Benefits. The second level appeal will be conducted and you will be
notified of the decision within 15 days from receipt of a request for review of the first level appeal
decision.

you will be notified of the decision within 30 days from receipt of a request for appeal of a denied
claim. The second level appeal will be conducted and you will be notified of the decision within 30
days from receipt of a request for review of the first level appeal decision.
Action below.
If you are not satisfied with the first level appeal decision, you have the right to request a second level
appeal. Your second level appeal request must be submitted to us within 60 days from receipt of the first
level appeal decision.
Please note that our decision is based only on whether or not Benefits are available under the Policy for
the proposed treatment or procedure. We don't determine whether the pending health service is
necessary or appropriate. That decision is between you and your Physician.
Your appeal may require immediate action if a delay in treatment could significantly increase the risk to
your health, or the ability to regain maximum function, or cause severe pain. In these urgent situations:
IX

as possible.

X
Medical Information Privacy Notice
This notice describes how medical information about you may be used and disclosed and how
We* are required by law to protect the privacy of your health information. We are also required to send
you this notice, which explains how we may use information about you and when we can give out or
"disclose" that information to others. You also have rights regarding your health information that are
described in this notice. We are required by law to abide by the terms of this notice.
The terms "information" or "health information" in this notice include any information we maintain that
reasonably can be used to identify you and that relates to your physical or mental health condition, the
provision of health care to you, or the payment for such health care.
We have the right to change our privacy practices and the terms of this notice. If we make a material
change to our privacy practices, we will provide to you a revised notice by direct mail or electronically as
permitted by applicable law. In all cases, we will post the revised notice on our website www.myuhc.com.
We reserve the right to make any revised or changed notice effective for information we already have and
for information that we receive in the future.
*For purposes of this Notice of Privacy Practices, "we" or "us" refers to the following health plans that are
affiliated with UnitedHealth Group:
ACN Group of California, Inc.; All Savers Insurance Company; All Savers Life Insurance Company of
California; American Medical Security Life Insurance Company; AmeriChoice of Connecticut, Inc.;
AmeriChoice of Georgia, Inc.; AmeriChoice of New Jersey, Inc.; Arizona Physicians IPA, Inc.; Citrus
Health Care, Inc.; Dental Benefit Providers of California, Inc.; Dental Benefit Providers of Illinois, Inc.;
Evercare of Arizona, Inc.; Evercare of New Mexico, Inc.; Evercare of Texas, LLC; Golden Rule Insurance
Company; Health Plan of Nevada, Inc.; MAMSI Life and Health Insurance Company; MD-Individual
Practice Association, Inc.; Midwest Security Life Insurance Company; National Pacific Dental, Inc.;
Neighborhood Health Partnership, Inc.; Nevada Pacific Dental; Optimum Choice, Inc.; Oxford Health
Insurance, Inc.; Oxford Health Plans (CT), Inc.; Oxford Health Plans (NJ), Inc.; Oxford Health Plans (NY),
Inc.; PacifiCare Life and Health Insurance Company; PacifiCare Life Assurance Company; Physicians
Health Choice of Texas, LLC; Sierra Health & Life Insurance Co., Inc.; UHC of California; U.S. Behavioral
Health Plan, California; Unimerica Insurance Company; Unimerica Life Insurance Company of New York;
Unison Family Health Plan of Pennsylvania, Inc.; Unison Health Plan of Delaware, Inc.; Unison Health
Plan of Pennsylvania, Inc.; Unison Health Plan of Tennessee, Inc.; Unison Health Plan of the Capital
Area, Inc.; United Behavioral Health; UnitedHealthcare Benefits of Texas, Inc.; UnitedHealthcare
Community Plan of Ohio, Inc.; UnitedHealthcare Insurance Company; UnitedHealthcare Insurance
Company of Illinois; UnitedHealthcare Insurance Company of New York; UnitedHealthcare Insurance
Company of the River Valley; UnitedHealthcare Insurance Company of Ohio; UnitedHealthcare of
Alabama, Inc.; UnitedHealthcare of Arizona, Inc.; UnitedHealthcare of Arkansas, Inc.; UnitedHealthcare of
Colorado, Inc.; UnitedHealthcare of Florida, Inc.; UnitedHealthcare of Georgia, Inc.; UnitedHealthcare of
Illinois, Inc.; UnitedHealthcare of Kentucky, Ltd.; UnitedHealthcare of Louisiana, Inc.; UnitedHealthcare of
the Mid-Atlantic, Inc.; UnitedHealthcare of the Great Lakes Health Plan, Inc.; UnitedHealthcare of the
Midlands, Inc.; UnitedHealthcare of the Midwest, Inc.; United HealthCare of Mississippi, Inc.;
UnitedHealthcare of New England, Inc.; UnitedHealthcare of New York, Inc.; UnitedHealthcare of North
Carolina, Inc.; UnitedHealthcare of Ohio, Inc.; UnitedHealthcare of Oklahoma, Inc.; UnitedHealthcare of
Oregon, Inc.; UnitedHealthcare of Pennsylvania, Inc.; UnitedHealthcare of South Carolina, Inc.;
UnitedHealthcare of Texas, Inc.; UnitedHealthcare of Utah, Inc.; UnitedHealthcare of Washington, Inc.;
UnitedHealthcare of Wisconsin, Inc.; UnitedHealthcare Plan of the River Valley, Inc.
XI
How We Use or Disclose Information
We must use and disclose your health information to provide that information:

To you or someone who has the legal right to act for you (your personal representative) in order to
administer your rights as described in this notice; and

To the Secretary of the Department of Health and Human Services, if necessary, to make sure
your privacy is protected.
We have the right to use and disclose health information for your treatment, to pay for your health care
and to operate our business. For example, we may use or disclose your health information:

For Payment of premiums due us, to determine your coverage, and to process claims for health
care services you receive, including for subrogation or coordination of other benefits you may have.
For example, we may tell a doctor whether you are eligible for coverage and what percentage of
the bill may be covered.

For Treatment. We may use or disclose health information to aid in your treatment or the
coordination of your care. For example, we may disclose information to your physicians or hospitals
to help them provide medical care to you.

For Health Care Operations. We may use or disclose health information as necessary to operate
and manage our business activities related to providing and managing your health care coverage.
For example, we might talk to your physician to suggest a disease management or wellness
program that could help improve your health or we may analyze data to determine how we can
improve our services.

To Provide You Information on Health Related Programs or Products such as alternative
medical treatments and programs or about health-related products and services, subject to limits
imposed by law.

For Plan Sponsors. If your coverage is through an employer sponsored group health plan, we
may share summary health information and enrollment and disenrollment information with the plan
sponsor. In addition, we may share other health information with the plan sponsor for plan
administration if the plan sponsor agrees to special restrictions on its use and disclosure of the
information in accordance with federal law.

For Reminders. We may use or disclose health information to send you reminders about your
benefits or care, such as appointment reminders with providers who provide medical care to you.
We may use or disclose your health information for the following purposes under limited circumstances:

As Required by Law. We may disclose information when required to do so by law.

To Persons Involved With Your Care. We may use or disclose your health information to a
person involved in your care or who helps pay for your care, such as a family member, when you
are incapacitated or in an emergency, or when you agree or fail to object when given the
opportunity. If you are unavailable or unable to object, we will use our best judgment to decide if
the disclosure is in your best interests.

For Public Health Activities such as reporting or preventing disease outbreaks.

For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that
are authorized by law to receive such information, including a social service or protective service
agency.

For Health Oversight Activities to a health oversight agency for activities authorized by law, such
as licensure, governmental audits and fraud and abuse investigations.
XII

For Judicial or Administrative Proceedings such as in response to a court order, search warrant
or subpoena.

For Law Enforcement Purposes. We may disclose your health information to a law enforcement
official for purposes such as providing limited information to locate a missing person or report a
crime.

To Avoid a Serious Threat to Health or Safety to you, another person or the public by, for
example, disclosing information to public health agencies or law enforcement authorities, or in the
event of an emergency or natural disaster.

For Specialized Government Functions such as military and veteran activities, national security
and intelligence activities, and the protective services for the President and others.

For Workers' Compensation as authorized by, or to the extent necessary to comply with, state
workers compensation laws that govern job-related injuries or illness.

For Research Purposes such as research related to the evaluation of certain treatments or the
prevention of disease or disability, if the research study meets privacy law requirements.

To Provide Information Regarding Decedents. We may disclose information to a coroner or
medical examiner to identify a deceased person, determine a cause of death, or as authorized by
law. We may also disclose information to funeral directors as necessary to carry out their duties.

For Organ Procurement Purposes. We may use or disclose information to entities that handle
procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and
transplantation.

To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional
institution or under the custody of a law enforcement official, but only if necessary (1) for the
institution to provide you with health care; (2) to protect your health and safety or the health and
safety of others; or (3) for the safety and security of the correctional institution.

To Business Associates that perform functions on our behalf or provide us with services if the
information is necessary for such functions or services. Our business associates are required,
under contract with us, to protect the privacy of your information and are not allowed to use or
disclose any information other than as specified in our contract.

For Data Breach Notification Purposes. We may use your contact information to provide legallyrequired notices of unauthorized acquisition, access, or disclosure of your health information. We
may send notice directly to you or provide notice to the sponsor of your plan through which you
receive coverage.
Additional Restrictions on Use and Disclosure
Certain federal and state laws may require special privacy protections that restrict the use and disclosure
of certain health information, including highly confidential information about you. "Highly confidential
information" may include confidential information under Federal laws governing alcohol and drug abuse
information and genetic information as well as state laws that often protect the following types of
information:

HIV/AIDS;

Mental health;

Genetic tests;

Alcohol and drug abuse;
XIII

Sexually transmitted diseases and reproductive health information; and

Child or adult abuse or neglect, including sexual assault.
If a use or disclosure of health information described above in this notice is prohibited or materially limited
by other laws that apply to us, it is our intent to meet the requirements of the more stringent law. Attached
to this notice is a summary of federal and state laws on use and disclosure of certain types of medical
information.
Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose
your health information only with a written authorization from you. Once you give us authorization to
release your health information, we cannot guarantee that the person to whom the information is provided
will not disclose the information. You may take back or "revoke" your written authorization at anytime in
writing, except if we have already acted based on your authorization. To find out where to mail your
written authorization and how to revoke an authorization, contact the phone number listed on the back of
your ID card.
What Are Your Rights
The following are your rights with respect to your health information:

You have the right to ask to restrict uses or disclosures of your information for treatment,
payment, or health care operations. You also have the right to ask to restrict disclosures to family
members or to others who are involved in your health care or payment for your health care. We
may also have policies on dependent access that authorize your dependents to request certain
restrictions. Please note that while we will try to honor your request and will permit requests
consistent with our policies, we are not required to agree to any restriction.

You have the right to ask to receive confidential communications of information in a different
manner or at a different place (for example, by sending information to a P.O. Box instead of your
home address). We will accommodate reasonable requests where a disclosure of all or part of your
health information otherwise could endanger you. We will accept verbal requests to receive
confidential communications, but requests to modify or cancel a previous confidential
communication request must be made in writing. Mail your request to the address listed below.

You have the right to see and obtain a copy of health information that may be used to make
decisions about you such as claims and case or medical management records. You also may in
some cases receive a summary of this health information. You must make a written request to
inspect and copy your health information. Mail your request to the address listed below. In certain
limited circumstances, we may deny your request to inspect and copy your health information. We
may charge a reasonable fee for any copies. If we deny your request, you have the right to have
the denial reviewed. If we maintain an electronic health record containing your health information,
when and if we are required by law, you will have the right to request that we send a copy of your
health information in an electronic format to you or to a third party that you identify. We may charge
a reasonable fee for sending the electronic copy of your health information.

You have the right to ask to amend information we maintain about you if you believe the health
information about you is wrong or incomplete. Your request must be in writing and provide the
reasons for the requested amendment. Mail your request to the address listed below. If we deny
your request, you may have a statement of your disagreement added to your health information.

You have the right to receive an accounting of certain disclosures of your information made by
us during the six years prior to your request. This accounting will not include disclosures of
information made: (i) prior to April 14, 2003; (ii) for treatment, payment and health care operations
purposes; (iii) to you or pursuant to your authorization; (iv) to correctional institutions or law
enforcement officials; and (v) other disclosures for which federal law does not require us to provide
an accounting.
XIV

You have the right to a paper copy of this notice. You may ask for a copy of this notice at any
time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper
copy of this notice. You also may obtain a copy of this notice at our website, www.myuhc.com.
Exercising Your Rights

Contacting your Health Plan. If you have any questions about this notice or want to exercise any
of your rights, please call the toll-free phone number on the back of your ID card or you may
contact the UnitedHealth Group Customer Call Center at 866-633-2446.

Submitting a Written Request. Mail to us your written requests for modifying or cancelling a
confidential communication, for copies of your records, or for amendments to your record, at the
following address:
UnitedHealthcare
Customer Service - Privacy Unit
PO Box 740815
Atlanta, GA 30374-0815

Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint
with us at the address listed above.
You may also notify the Secretary of the U.S. Department of Health and Human Services of your
complaint. We will not take any action against you for filing a complaint.
XV
This notice describes how financial information about you may be used and disclosed and how
We** are committed to maintaining the confidentiality of your personal financial information. For the
purposes of this notice, "personal financial information" means information about an enrollee or an
applicant for health care coverage that identifies the individual, is not generally publicly available and is
collected from the individual or is obtained in connection with providing health care coverage to the
individual.
Information We Collect
We collect personal financial information about you from the following sources:

Information we receive from you on applications or other forms, such as name, address, age,
medical information and Social Security number.

Information about your transactions with us, our affiliates or others, such as premium payment and
claims history.

Information from consumer reports.
Disclosure of Information
We do not disclose personal financial information about our enrollees or former enrollees to any third
party, except as required or permitted by law. For example, in the course of our general business
practices, we may, as permitted by law, disclose any of the personal financial information that we collect
about you, without your authorization, to the following types of institutions:

To our corporate affiliates, which include financial service providers, such as other insurers, and
non-financial companies, such as data processors.

To nonaffiliated companies for our everyday business purposes, such as to process your
transactions, maintain your account(s), or respond to court orders and legal investigations.

To nonaffiliated companies that perform services for us, including sending promotional
communications on our behalf.
For purposes of this Financial Information Privacy Notice, "we" or "us" refers to the entities listed on the
first page of the Health Plan Notices of Privacy Practices, plus the following UnitedHealthcare affiliates:
AmeriChoice Health Services, Inc.; DBP Services of New York IPA, Inc.; DCG Resource Options, LLC;
Dental Benefit Providers, Inc.; Dental Benefit Providers of California, Inc.; Dental Benefit Providers of
Illinois, Inc.; Disability Consulting Group, LLC; HealthAllies, Inc.; MAMSI Insurance Resources, LLC;
Managed Physical Network, Inc.; Mid Atlantic Medical Services, LLC; National Pacific Dental, Inc.;
Nevada Pacific Dental; OneNet PPO, LLC; Oxford Benefit Management, Inc.; Oxford Health Plans LLC;
PacifiCare Health Plan Administrators, Inc.; ProcessWorks, Inc.; Spectera, Inc.; Spectera of New York,
IPA, Inc.; UMR, Inc.; Unimerica Insurance Company; Unimerica Life Insurance Company of New York;
Unison Administrative Services, LLC; United Behavioral Health of New York I.P.A., Inc.; United
HealthCare Services, Inc.; UnitedHealth Advisors, LLC; UnitedHealthcare Service LLC; UnitedHealthcare
Services Company of the River Valley, Inc.; UnitedHealthOne Agency, Inc. This Financial Information
Privacy Notice only applies where required by law. Specifically, it does not apply to (1) health care
insurance products offered in Nevada by Health Plan of Nevada, Inc. and Sierra Health and Life
Insurance Company, Inc.; or (2) other UnitedHealth Group health plans in states that provide exceptions
for HIPAA covered entities or health insurance products.
XVI
Confidentiality and Security
We restrict access to personal financial information about you to our employees and service providers
who are involved in administering your health care coverage and providing services to you. We maintain
physical, electronic and procedural safeguards in compliance with state and federal standards to guard
your personal financial information. We conduct regular audits to help ensure appropriate and secure
handling and processing of our enrollees' information.
Questions about this Notice
If you have any questions about this notice, please call the toll-free phone number on the back of your ID
card or you may contact the UnitedHealth Group Customer Call Center at 866-633-2446.
XVII
UnitedHealth Group
Amendments
The first part of this Notice, which provides our privacy practices for Medical Information, describes how
we may use and disclose your health information under federal privacy rules. There are other laws that
may limit our rights to use and disclose your health information beyond what we are allowed to do under
the federal privacy rules. The purpose of the charts below is to:

Show the categories of health information that are subject to these more restrictive laws.

Give you a general summary of when we can use and disclose your health information without your
consent.
If your written consent is required under the more restrictive laws, the consent must meet the particular
rules of the applicable federal or state law.
Summary of Federal Laws
Alcohol & Drug Abuse Information
We are allowed to use and disclose alcohol and drug abuse information that is protected by federal
law only (1) in certain limited circumstances, and/or disclose only (2) to specific recipients.
Genetic Information
We are not allowed to use genetic information for underwriting purposes.
Summary of State Laws
General Health Information
We are allowed to disclose general health
CA, NE, PR, RI, VT, WA, WI
HMOs must give enrollees an opportunity to
approve or refuse disclosures, subject to certain
exceptions.
KY
You may be able to restrict certain electronic
disclosures of health information.
NV
We are not allowed to use health information for
certain purposes.
CA
We will not use and/or disclose information
regarding certain public assistance programs
except for certain purposes.
MO, NJ, SD
Prescriptions
We are allowed to disclose prescription-related
ID, NH, NV
XVIII
Communicable Diseases
We are allowed to disclose communicable
disease information only (1) under certain limited
AZ, IN, KS, MI, NV, OK
Sexually Transmitted Diseases and Reproductive Health
CA, FL, HI, IN, KS, MI, MT, NJ, NV, PR, WA,
WY
We are allowed to disclose sexually transmitted
disease and/or reproductive health information
Alcohol and Drug Abuse
We are allowed to use and disclose alcohol and
drug abuse information (1) under certain limited
circumstances, and/or disclose only (2) to specific
recipients.
CT, GA, HI, KY, IL, IN, IA, LA, NC, NH, WA, WI
Disclosures of alcohol and drug abuse information
may be restricted by the individual who is the
subject of the information.
WA
Genetic Information
We are not allowed to disclose genetic information
without your written consent.
CA, CO, HI, IL, KS, KY, LA, NY, RI, TN, WY
We are allowed to disclose genetic information
AK, AZ, FL, GA, IA, MD, MA, MO, NJ, NV, NH,
NM, OR, RI, TX, UT, VT
Restrictions apply to (1) the use, and/or (2) the
retention of genetic information.
FL, GA, IA, LA, MD, NM, OH, UT, VA, VT
HIV / AIDS
We are allowed to disclose HIV/AIDS-related
AZ, AR, CA, CT, DE, FL, GA, HI, IA, IL, IN, KS,
KY, ME, MI, MO, MT, NY, NC, NH, NM, NV,
OR, PA, PR, RI, TX, VT, WA, WI, WV, WY
HIV/AIDS-related information.
CT, FL
Mental Health
We are allowed to disclose mental health
CA, CT, DC, HI, IA, IL, IN, KY, MA, MI, NC, NM,
PR, TN, WA, WI
Disclosures may be restricted by the individual
who is the subject of the information.
WA
mental health information.
CT
Certain restrictions apply to the use of mental
health information.
ME
XIX
Child or Adult Abuse
We are allowed to use and disclose child and/or
adult abuse information only (1) under certain
limited circumstances, and/or disclose only (2) to
specific recipients.
AL, CO, IL, LA, NE, NJ, NM, RI, TN, TX, UT, WI
XX
(ERISA) Rights
As a participant in the plan, you are entitled to certain rights and protections under the Employee
Retirement Income Security Act of 1974 (ERISA).
Receive Information about Your Plan and Benefits
You are entitled to examine, without charge, at the Plan Administrator's office and at other specified
locations, such as worksites and union halls, all documents governing the plan, including insurance
contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500
Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room
of the Employee Benefits Security Administration.
You are entitled to obtain, upon written request to the Plan Administrator, copies of documents governing
the operation of the plan, including insurance contracts and collective bargaining agreements, and copies
of the latest annual report (Form 5500 Series) and updated Summary Plan Description. The Plan
Administrator may make a reasonable charge for the copies.
You are entitled to continue health care coverage for yourself, spouse or Dependents if there is a loss of
coverage under the plan as a result of a qualifying event. You or your Dependents may have to pay for
such coverage. The Plan Sponsor is responsible for providing you notice of your COBRA continuation
rights. Review the Summary Plan Description and the documents governing the plan on the rules
governing your COBRA continuation coverage rights.
You are entitled to a reduction or elimination of exclusionary periods of coverage for preexisting
conditions under your group health plan, if you have creditable coverage from another group health plan.
You should be provided a certificate of creditable coverage, in writing, free of charge, from your group
health plan or health insurance issuer when you lose coverage under the plan, when you become entitled
to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request
it before losing coverage, or if you request it up to 24 months after losing coverage. You may request a
certificate of creditable coverage by calling the number on the back of your ID card. Without evidence of
creditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18 months
for late enrollees) after your enrollment date in your coverage.
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are
responsible for the operation of the employee benefit plan. The people who operate your plan, called
"fiduciaries" of the plan, have a duty to do so prudently and in the interest of you and other plan
participants and beneficiaries. No one, including your employer, your union, or any other person may fire
you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or
exercising your rights under ERISA.
Enforce Your Rights
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why
this was done, to obtain copies of documents relating to the decision without charge, and to appeal any
denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above
rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and
do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may
require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the
XXI
materials, unless the materials were not sent because of reasons beyond the control of the Plan
Administrator. If you have a claim for Benefits which is denied or ignored, in whole or in part, you may file
suit in a state or Federal court. In addition, if you disagree with the plan's decision or lack thereof
concerning the qualified status of a domestic relations order or a medical child support order, you may file
suit in Federal court. If it should happen that plan fiduciaries misuse the plan's money, or if you are
discriminated against for asserting your rights, you may seek assistance from the U.S. Department of
Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal
fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If
you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is
frivolous.
If you have any questions about your plan, you should contact the Plan Administrator. If you have any
questions about this statement or about your rights under ERISA, or if you need assistance in obtaining
documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits
Security Administration, U. S. Department of Labor listed in your telephone directory or the Division of
Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of
Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210. You may also obtain certain publications
about your rights and responsibilities under ERISA by calling the publication hotline of the Employee
Benefits Security Administration.
XXII
ERISA Statement
If the Enrolling Group is subject to ERISA, the following information applies to you.
Summary Plan Description
Name of Plan: Tekmark Global Solutions Employee Benefit Plan
Name, Address and Telephone Number of Plan Sponsor and Named Fiduciary:
100 Metroplex Drive
Edison, NJ 08817
(732) 572-9600
The Plan Sponsor retains all fiduciary responsibilities with respect to the Plan except to the extent the
Plan Sponsor has delegated or allocated to other persons or entities one or more fiduciary responsibility
with respect to the Plan.
Claims Fiduciary:
Employer Identification Number (EIN): 22-3532457
IRS Plan Number: 501
Effective Date of Plan: The effective date of the Plan is April 1, 2006; the effective date of this
restatement of the Plan is April 1, 2013
Type of Plan: Health care coverage plan
Name, business address, and business telephone number of Plan Administrator:
100 Metroplex Drive
Edison, NJ 08817
(732) 572-9600
Type of Administration of the Plan:
Benefits are paid pursuant to the terms of a group health policy issued and insured by:
185 Asylum Street
Hartford, CT 06103-3408
The Plan is administered on behalf of the Plan Administrator by UnitedHealthcare Insurance Company
pursuant to the terms of the group Policy. UnitedHealthcare Insurance Company provides administrative
services for the Plan including claims processing, claims payment, and handling appeals.
Person designated as agent for service of legal process: Plan Administrator
Source of contributions and funding under the Plan: There are no contributions to the Plan. Any
required employee contributions are used to partially reimburse the Plan Sponsor for Premiums under the
Plan. Benefits under the Plan are funded by the payment of Premium required by the group Policy.
Method of calculating the amount of contribution: Employee-required contributions to the Plan
Sponsor are the employee's share of costs as determined by Plan Sponsor. From time to time, the Plan
XXIII
Sponsor will determine the required employee contributions for reimbursement to the Plan Sponsor and
distribute a schedule of such required contributions to employees.
Date of the end of the year for purposes of maintaining Plan's fiscal records:
Plan year shall be a 12 month period ending April 1.
Determinations of Qualified Medical Child Support Orders: The plan's procedures for handling
qualified medical child support orders are available without charge upon request to the Plan
Administrator.
XXIV
YOUR
GROUP INSURANCE
PLAN
TEKMARK GLOBAL SOLUTIONS, LLC.
CLASS 0001
OPTIONAL LIFE, DENTAL, LONG TERM DISABILITY, VISION
CERTIFICATE OF COVERAGE
The Guardian
7 Hanover Square
New York, New York 10004
We, The Guardian, certify that the employee named below is
entitled to the insurance benefits provided by The Guardian
described in this certificate, provided the eligibility and effective
date requirements of the plan are satisfied.
Group Policy No.
Certificate No.
Effective Date
Issued To
This CERTIFICATE OF COVERAGE replaces any CERTIFICATE
OF COVERAGE previously issued under the above Plan or under
any other Plan providing similar or identical benefits issued to the
Planholder by The Guardian.
B110.0023
00283190/00063.0/A /T68069/9999/0001
TABLE OF CONTENTS
IMPORTANT NOTICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
SECTION I: Employer-Funded Benefits Not Insured By Guardian
An Important Notice About Continuation Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
YOUR CONTINUATION RIGHTS
Federal Continuation Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Uniformed Services Continuation Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
ELIGIBILITY FOR DENTAL COVERAGE
Employee Coverage . . . . . . . . . . . . . . .
Your Right To Continue Group Coverage
A Family Leave Of Absence . . . . . . . . .
Dependent Coverage . . . . . . . . . . . . . .
DENTAL HIGHLIGHTS
.................................... 9
During
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
DENTAL EXPENSE INSURANCE
DentalGuard Preferred - This Plan’s Dental
Preferred Provider Organization . . . . . . . . . .
Covered Charges . . . . . . . . . . . . . . . . . . . .
Alternate Treatment . . . . . . . . . . . . . . . . . . .
Proof of Claim . . . . . . . . . . . . . . . . . . . . . . .
Pre-Treatment Review . . . . . . . . . . . . . . . . .
Benefits From Other Sources . . . . . . . . . . . .
The Benefit Provision - Qualifying For Benefits
Rollover of Benefit Year Payment Limit for
Group I, II and III Non-Orthodontic Services . .
After This Insurance Ends . . . . . . . . . . . . . .
Extended Dental Expense Benefits . . . . . . . .
Special Limitations . . . . . . . . . . . . . . . . . . . .
Exclusions . . . . . . . . . . . . . . . . . . . . . . . . .
List of Covered Dental Services . . . . . . . . . .
Group I - Preventive Dental Services . . . . . . .
Group II - Basic Dental Services . . . . . . . . . .
Group III - Major Dental Services . . . . . . . . .
.
.
.
.
.
.
.
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16
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19
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20
22
22
23
23
26
26
27
32
DISCOUNT - THIS IS NOT INSURANCE
Discounts on Dental Services Not Covered By This Plan . . . . . . . . . . . . . . . . . . . . . . . 34
Discounts on Services Not Covered Due To
Contractual Provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Discounts on Orthodontic Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
COORDINATION OF BENEFITS
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Order Of Benefit Determination . . . . . . . . . . . . . . .
Effect On The Benefits Of This Plan . . . . . . . . . . .
Right To Receive And Release Needed Information
Facility Of Payment . . . . . . . . . . . . . . . . . . . . . . .
Right Of Recovery . . . . . . . . . . . . . . . . . . . . . . . .
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36
38
39
40
40
40
SUBROGATION AND RIGHT OF RECOVERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
00283190/00063.0/A /T68069/9999/0001
TABLE OF CONTENTS (CONT.)
STATEMENT OF ERISA RIGHTS
The Guardian’s Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Group Health Benefits Claims Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Termination of This Group Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
SECTION II: Guardian Insurance
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
GENERAL PROVISIONS
Limitation of Authority . . . . . . . . . . . . . . . . . .
Incontestability . . . . . . . . . . . . . . . . . . . . . . . .
Examination and Autopsy . . . . . . . . . . . . . . . .
Accident and Health Claims Provisions . . . . . .
Coordination Between Continuation Sections . .
An Important Notice About Continuation Rights
Federal Continuation Rights . . . . . . . . .
Uniformed Services Continuation Rights
Important Notice . . . . . . . . . . . . . . . . .
A Totally Disabled Employee’s Right to
Continue Group Health Benefits . . . . . .
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57
57
58
58
60
61
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
SCHEDULE OF INSURANCE
Employee Long Term Disability Income Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
ELIGIBILITY FOR LIFE COVERAGES
Employee Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Your Right To Continue Group Life Insurance
During A Family Leave Of Absence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Dependent Life Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
GROUP TERM LIFE INSURANCE SCHEDULE
Employee Optional Contributory Term Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Dependent Optional Term Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
LIFE INSURANCE
Your Optional Group Term Life Insurance . . . . . . . . . . . . .
Converting This Group Term Life Insurance . . . . . . . . . . . .
Your Extended Life Benefit . . . . . . . . . . . . . . . . . . . . . . . .
Dependent Spouse And Child Optional Term Life Insurance
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80
82
83
84
ELIGIBILITY FOR DISABILITY COVERAGE
Employee Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
LONG TERM DISABILITY INCOME INSURANCE
General Definitions Which Apply To Your
Long Term Disability Income Insurance . . . .
How This Plan Works . . . . . . . . . . . . . . . .
Special Limitations . . . . . . . . . . . . . . . . . . .
Exclusions . . . . . . . . . . . . . . . . . . . . . . . .
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88
90
94
95
VISION DISCOUNT PROGRAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
TABLE OF CONTENTS (CONT.)
GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
SUMMARY PLAN DESCRIPTION SUPPLEMENT TO CERTIFICATE . . . . . . . . . . . . . . . . . . 99
STATEMENT OF ERISA RIGHTS
The Guardian’s Responsibilities . . . . . . . . . . . . . . . . .
Disability And Group Health Benefits Claims Procedure
Termination of This Group Plan . . . . . . . . . . . . . . . . .
Life Insurance Claims Procedure . . . . . . . . . . . . . . . . .
Termination of This Group Plan . . . . . . . . . . . . . . . . .
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102
103
108
109
110
IMPORTANT NOTICE
SECTION I
The benefits described in Section I of this booklet are directly funded through
and provided by your employer, and are not insured by Guardian.
Your employer, has the sole responsibility and liability for payment of these
benefits. Guardian supplies administrative services, such as: claims services
and preparation of employee benefit booklets.
As used in Section I of this booklet, the terms:
"certificate" refers to this booklet describing the benefits directly funded
through and provided by your employer;
"insurance" and "insured" refers to the benefits directly funded through
and provided by your employer;
"plan", "we", "us" and "our" refer to the benefits that are directly
funded through and provided by your employer, and are not insured by
Guardian;
"premium," "premiums," and "premium charge" refer to payments
required from you for coverage under this plan; and
"proof of insurability" refers to any evidence of your good health which
may be required under this plan.
All terms and provisions, maximums or limitations set forth in Section I of this
Certificate Booklet will be applicable to the benefits described in Section I of
this booklet and provided by your employer.
SECTION II
These benefits are purchased and provided through a group insurance plan
issued by Guardian to your employer.
B115.0127
00283190/00063.0/A /T68069/9999/0001
P. 1
SECTION I: Employer-Funded Benefits Not Insured By Guardian
B115.0002
00283190/00063.0/A /T68069/9999/0001
P. 3
An Important Notice About Continuation Rights
The following "Federal Continuation Rights" section may not apply to the
employer’s plan. You must contact your employer to find out if: (a) the
employer is subject to the "Federal Continuation Rights" section, and
therefore; (b) the section applies to you.
B235.0109
00283190/00063.0/A /T68069/9999/0001
P. 4
Federal Continuation Rights
Important Notice
This section applies only to any dental, out-of-network point-of-service
medical, major medical, prescription drug or vision coverages which are part
of this plan. In this section, these coverages are referred to as "group health
benefits."
This section does not apply to any coverage for loss of income due to
disability. This coverage can not be continued under this section.
Under this section, "qualified continuee" means any person who, on the day
before any event which would qualify him or her for continuation under this
section, is covered for group health benefits under this plan as: (a) an active,
covered employee; (b) the spouse of an active, covered employee; or (c) the
dependent child of an active covered employee. A child born to, or adopted
by, the covered employee during a continuation period is also a qualified
continuee. Any other person who becomes covered under this plan during a
continuation provided by this section is not a qualified continuee.
If Your Group If you are a qualified continuee and your group health benefits end due to
Health Benefits End your termination of employment or reduction of work hours, you may elect to
continue such benefits for up to 18 months, if you were not terminated due
to gross misconduct.
The continuation: (a) may cover you or any other qualified continuee; and (b)
is subject to "When Continuation Ends".
Extra Continuation
for Disabled
Qualified
Continuees
If a qualified continuee is determined to be disabled under Title II or Title XVI
of the Social Security Act on or during the first 60 days after the date his or
her group health benefits would otherwise end due to your termination of
employment or reduction of work hours, and such disability lasts at least until
the end of the 18 month period of continuation coverage, he or she or any
member of that person’s family who is a qualified continuee may elect to
extend his or her 18 month continuation period explained above for up to an
extra 11 months.
To elect the extra 11 months of continuation, a qualified continuee must give
your employer written proof of Social Security’s determination of the disabled
qualified continuee’s disability as described in "The Qualified Continuee’s
Responsibilities". If, during this extra 11 month continuation period, the
qualified continuee is determined to be no longer disabled under the Social
Security Act, he or she must notify your employer within 30 days of such
determination, and continuation will end, as explained in "When Continuation
Ends."
This extra 11 month continuation is subject to "When Continuation Ends".
An additional 50% of the total cost of coverage also may be required from all
qualified continuees who are members of the disabled qualified continuee’s
family by your employer during this extra 11 month continuation period,
provided the disabled qualified continuee has extended coverage.
B235.0148
00283190/00063.0/A /T68069/9999/0001
P. 5
If You Die While If you die while covered, any qualified continuee whose group health benefits
Covered would otherwise end may elect to continue such benefits. The continuation
can last for up to 36 months, subject to "When Continuation Ends".
If Your Marriage If your marriage ends due to legal divorce or legal separation, any qualified
Ends continuee whose group health benefits would otherwise end may elect to
continue such benefits. The continuation can last for up to 36 months,
subject to "When Continuation Ends".
If a Dependent If a dependent child’s group health benefits end due to his or her loss of
Child Loses dependent eligibility as defined in this plan, other than your coverage ending,
Eligibility he or she may elect to continue such benefits. However, such dependent
child must be a qualified continuee. The continuation can last for up to 36
months, subject to "When Continuation Ends".
Concurrent
Continuations
If a dependent elects to continue his or her group health benefits due to your
termination of employment or reduction of work hours, the dependent may
elect to extend his or her 18 month or 29 month continuation period to up to
36 months, if during the 18 month or 29 month continuation period, the
dependent becomes eligible for 36 months of continuation due to any of the
reasons stated above.
The 36 month continuation period starts on the date the 18 month
continuation period started, and the two continuation periods will be deemed
to have run concurrently.
Special Medicare If you become entitled to Medicare before a termination of employment or
Rule reduction of work hours, a special rule applies for a dependent. The
continuation period for a dependent, after your later termination of
employment or reduction of work hours, will be the longer of: (a) 18 months
(29 months if there is a disability extension) from your termination of
employment or reduction of work hours; or (b) 36 months from the date of
your earlier entitlement to Medicare. If Medicare entitlement occurs more
than 18 months before termination of employment or reduction of work
hours, this special Medicare rule does not apply.
The Qualified
Continuee’s
Responsibilities
A person eligible for continuation under this section must notify your
employer, in writing, of: (a) your legal divorce or legal separation from your
spouse; (b) the loss of dependent eligibility, as defined in this plan, of a
covered dependent child; (c) a second event that would qualify a person for
continuation coverage after a qualified continuee has become entitled to
continuation with a maximum of 18 or 29 months; (d) a determination by the
Social Security Administration that a qualified continuee entitled to receive
continuation with a maximum of 18 months has become disabled during the
first 60 days of such continuation; and (e) a determination by the Social
Security Administration that a qualified continuee is no longer disabled.
Notice of an event that would qualify a person for continuation under this
section must be given to your employer within 60 days of the latest of: (a)
the date on which an event that would qualify a person for continuation under
this section occurs; (b) the date on which the qualified continuee loses (or
would lose) coverage under this plan as a result of the event; or (c) the date
the qualified continuee is informed of the responsibility to provide notice to
your employer and this plan’s procedures for providing such notice.
00283190/00063.0/A /T68069/9999/0001
P. 6
Notice of a disability determination must be given to your employer by a
qualified continuee within 60 days of the latest of: (a) the date of the Social
Security Administration determination; (b) the date of the event that would
qualify a person for continuation; (c) the date the qualified continuee loses or
would lose coverage; or (d) the date the qualified continuee is informed of
the responsibility to provide notice to your employer and this plan’s
procedures for providing such notice. But such notice must be given before
the end of the first 18 months of continuation coverage.
B235.0181
Your Employer’s Your employer must notify the qualified continuee, in writing, of: (a) his or
Responsibilities her right to continue this plan’s group health benefits; (b) the payments he or
she must make to continue such benefits; and (c) the times and manner in
which such payments must be made.
If your employer determines that an individual is not eligible for continued
group health benefits under this plan, they must notify the individual with an
explanation of why such coverage is not available. This notice must be
provided within the time frame described above.
If a qualified continuee’s continued group health benefits under this plan are
cancelled prior to the maximum continuation period, your employer must
notify the qualified continuee as soon as practical following determination that
the continued group health benefits shall terminate.
Election of
Continuation
To continue his or her group health benefits, the qualified continuee must
give your employer written notice that he or she elects to continue. This
must be done by the later of: (a) 60 days from the date a qualified continuee
receives notice of his or her continuation rights from your employer as
described above; or (b) the date coverage would otherwise end. And the
qualified continuee must make his or her first payment in a timely manner.
The subsequent payments must be paid to your employer, by the qualified
continuee, in advance, at the times and in the manner specified by your
employer. No further notice of when payments are due will be given.
The payment will be the total cost of coverage for the group health benefits
had the qualified continuee stayed covered under the group plan on a regular
basis. It includes any amount that would have been paid by your employer.
Except as explained in "Extra Continuation for Disabled Qualified
Continuees", an additional charge of two percent of the total cost of
coverage may also be required by your employer.
If the qualified continuee fails to give your employer notice of his or her
intent to continue, or fails to make any required payments in a timely
manner, he or she waives his or her continuation rights.
Grace in Payment
A qualified continuee’s payment is timely if, with respect to the first payment
after the qualified continuee elects to continue, such payment is made no
later than 45 days after such election. In all other cases, such payment is
timely if it is made within 31 days of the specified due date. If timely payment
is made to the plan in an amount that is not significantly less than the
amount the plan requires to be paid for the period of coverage, then the
amount paid is deemed to satisfy the requirement for the payment that must
be made; unless your employer notifies the qualified continuee of the amount
of the deficiency and grants an additional 30 days for payment of the
deficiency to be made. Payment is calculated to be made on the date on
which it is sent to your employer.
00283190/00063.0/A /T68069/9999/0001
P. 7
When Continuation A qualified continuee’s continued group health benefits end on the first of the
Ends following:
(1)
with respect to continuation upon your termination of employment or
reduction of work hours, the end of the 18 month period which starts on
the date the group health benefits would otherwise end;
(2)
with respect to a qualified continuee who has an additional 11 months
of continuation due to disability, the earlier of: (a) the end of the 29
month period which starts on the date the group health benefits would
otherwise end; or (b) the first day of the month which coincides with or
next follows the date which is 30 days after the date on which a final
determination is made that the disabled qualified continuee is no longer
disabled under Title II or Title XVI of the Social Security Act;
(3)
with respect to continuation upon your death, your legal divorce, or
legal separation, or the end of a covered dependent’s eligibility, the end
of the 36 month period which starts on the date the group health
benefits would otherwise end;
(4)
the date the employer ceases to provide any group health plan to any
employee;
(5)
the end of the period for which the last payment is made;
(6)
the date, after the date of election, he or she becomes covered under
any other group health plan which does not contain any pre-existing
condition exclusion or limitation affecting him or her; or
(7)
the date, after the date of election, he or she becomes entitled to
Medicare.
B235.0190
Uniformed Services Continuation Rights
If you enter or return from military service, you may have special rights under
this plan as a result of the Uniformed Services Employment and
Reemployment Rights Act of 1994 ("USERRA").
If your group health benefits under this plan would otherwise end because
you enter into active military service, this plan will allow you, or your
dependents, to continue such coverage in accord with the provisions of
USERRA. As used here, "group health benefits" means any dental,
out-of-network point-of service medical, major medical, prescription drug or
vision coverages which are part of this plan.
Coverage under this plan may be continued while you are in the military for
up to a maximum period of 24 months beginning on the date of absence
from work. Continued coverage will end if you fail to return to work in a
timely manner after military service ends as provided under USERRA. You
should contact your employer for details about this continuation provision
including required premium payments.
B235.0194
00283190/00063.0/A /T68069/9999/0001
P. 8
ELIGIBILITY FOR DENTAL COVERAGE
B489.0002
Employee Coverage
Eligible Employees
To be eligible for employee coverage you must be an active full-time
employee. And you must belong to a class of employees covered by this
plan.
Other Conditions
If you must pay all or part of the cost of employee coverage, we won’t insure
you until you enroll and agree to make the required payments. If you do this:
(a) more than 31 days after you first become eligible; or (b) after you
previously had coverage which ended because you failed to make a required
payment, we consider you to be a late entrant.
If you initially waived dental coverage under this plan because you were
covered under another group plan, and you now elect to enroll in the dental
coverage under this plan, the Penalty for Late Entrants provision will not
apply to you with regard to dental coverage provided your coverage under
the other plan ends due to one of the following events: (a) termination of
your spouse’s employment; (b) loss of eligibility under your spouse’s plan;
(c) divorce; (d) death of your spouse; or (e) termination of the other plan.
But you must enroll in the dental coverage under this plan within 30 days of
the date that any of the events described above occur.
B489.0365
When Your Employee benefits are scheduled to start on your effective date.
Coverage Starts
But you must be actively at work on a full-time basis on the scheduled
effective date. And you must have met all of the applicable conditions
explained above, and any applicable waiting period. If you are not actively at
work on the date your insurance is scheduled to start, we will postpone your
coverage until the date you return to active full-time work.
Sometimes, your effective date is not a regularly scheduled work day. But
coverage will still start on that date if you were actively at work on a full-time
basis on your last regularly scheduled work day.
B489.0356
When Your Your coverage ends on the last day of the month in which your active
Coverage Ends full-time service ends for any reason, other than disability. Such reasons
include retirement, layoff, leave of absence and the end of employment.
Your coverage ends on the date you die.
It also ends on the date you stop being a member of a class of employees
eligible for insurance under this plan, or when this plan ends for all
employees. And it ends when this plan is changed so that benefits for the
class of employees to which you belong ends.
00283190/00063.0/A /T68069/9999/0001
P. 9
Employee Coverage (Cont.)
If you are required to pay all or part of the cost of this coverage and you fail
to do so, your coverage ends. It ends on the last day of the period for which
you made the required payments, unless coverage ends earlier for other
reasons.
Read this booklet carefully if your coverage ends. You may have the right to
continue certain group benefits for a limited time.
B489.0374
Your Right To Continue Group Coverage During
A Family Leave Of Absence
Important Notice
This section may not apply. You must contact your employer to find out if
your employer must allow for a leave of absence under federal law. In that
case the section applies.
If Your Group Group coverage may normally end for an employee because he or she
Coverage Would ceases work due to an approved leave of absence. But, the employee may
End continue his or her group coverage if the leave of absence has been
granted: (a) to allow the employee to care for a seriously injured or ill
spouse, child, or parent; (b) after the birth or adoption of a child; (c) due to
the employee’s own serious health condition; or (d) because of any serious
injury or illness arising out of the fact that a spouse, child, parent, or next of
kin, who is a covered servicemember, of the employee is on active duty(or
has been notified of an impending call or order to active duty) in the Armed
Forces in support of a contingency operation. The employee will be required
to pay the same share of the premium as he or she paid before the leave of
absence.
When Continuation Coverage may continue until the earliest of the following:
Ends
The date you return to active work.
The end of a total leave period of 26 weeks in one 12 month period, in
the case of an employee who cares for a covered servicemember. This
26 week total leave period applies to all leaves granted to the employee
under this section for all reasons.
The end of a total leave period of 12 weeks in: (a) any 12 month
period, in the case of any other employee; or (b) any later 12 month
period in the case of an employee who cares for a covered
servicemember.
The date on which your coverage would have ended had you not been
on leave.
The end of the period for which the premium has been paid.
Definitions
As used in this section, the terms listed below have the meanings shown
below:
Active Duty: This term means duty under a call or order to active duty
in the Armed Forces of the United States.
00283190/00063.0/A /T68069/9999/0001
P. 10
Your Right To Continue Group Coverage During
A Family Leave Of Absence (Cont.)
Contingency Operation: This term means a military operation that: (a)
is designated by the Secretary of Defense as an operation in which
members of the armed forces are or may become involved in military
actions, operations, or hostilities against an enemy of the United States
or against an opposing military force; or (b) results in the call or order
to, or retention on, active duty of members of the uniformed services
under any provision of law during a war or during a national emergency
declared by the President or Congress.
Covered Servicemember: This term means a member of the Armed
Forces, including a member of the National Guard or Reserves, who for
a serious injury or illness: (a), is undergoing medical treatment,
recuperation, or therapy; (b) is otherwise in outpatient status; or (c) is
otherwise on the temporary disability retired list.
Next Of Kin: This term means the nearest blood relative of the
employee.
Outpatient Status: This term means, with respect to a covered
servicemember, that he or she is assigned to: (a) a military medical
treatment facility as an outpatient; or (b) a unit established for the
purpose of providing command and control of members of the Armed
Forces receiving medical care as outpatients.
Serious Injury Or Illness: This term means, in the case of a covered
servicemember, an injury or illness incurred by him or her in line of duty
on active duty in the Armed Forces that may render him or her
medically unfit to perform the duties of his or her office, grade, rank, or
rating.
B489.0359
Dependent Coverage
B200.0271
Eligible Dependents
For Dependent
Dental Benefits
Your eligible dependents are: (a) your legal spouse; (b) your unmarried
dependent children who are under age 20; and (c) your unmarried dependent
children from age 20 until their 26th birthday, who are enrolled as full-time
students at accredited schools.
An unmarried dependent child who is not able to remain enrolled as a
full-time student due to a medically necessary leave of absence may
continue to be an eligible dependent until the earlier of: (a) the date that is
one year after the first day of the medically necessary leave of absence; or
(b) the date on which coverage would otherwise end under this plan. You
must provide written certification by a treating physician which states that the
child is suffering from a serious illness or injury and that the leave of
absence is medically necessary.
00283190/00063.0/A /T68069/9999/0001
P. 11
Dependent Coverage (Cont.)
Your "legal spouse" includes a partner to a civil union when that union is in
accordance with New Jersey law. We treat the civil union partner as a
spouse in marriage, and the civil union as a marriage. Such unions also
include same-sex relationships from other jurisdictions that provide
substantially all of the rights and benefits of marriage.
B489.0311
Adopted Children
And Step-Children
Your "unmarried dependent children" include your legally adopted children
and, if they depend on you for most of their support and maintenance, your
step-children. We treat a child as legally adopted from the time the child is
placed in your home for the purpose of adoption. We treat such a child this
way whether or not a final adoption order is ever issued.
Dependents Not We exclude any dependent who is insured by this plan as an employee. And
Eligible we exclude any dependent who is on active duty in any armed force.
B264.0007
Handicapped
Children
You may have an unmarried child with a mental or physical handicap, or
developmental disability, who can’t support himself or herself. Subject to all
of the terms of this coverage and the plan, such a child may stay eligible for
dependent benefits past this coverage’s age limit.
The child will stay eligible as long as he or she stays unmarried and unable
to support himself or herself, if: (a) his or her conditions started before he or
she reached this coverage’s age limit; (b) he or she became insured by this
coverage before he or she reached the age limit, and stayed continuously
insured until he or she reached such limit; and (c) he or she depends on you
for most of his or her support and maintenance.
But, for the child to stay eligible, you must send us written proof that the
child is handicapped and depends on you for most of his or her support and
maintenance. You have 31 days from the date the child reaches the age limit
to do this. We can ask for periodic proof that the child’s condition continues.
But, after two years, we can’t ask for this proof more than once a year.
The child’s coverage ends when yours does.
B449.0042
Waiver Of Dental If you initially waived dental coverage for your spouse or eligible dependent
Late Entrants children under this plan because they were covered under another group
Penalty plan, and you now elect to enroll them in the dental coverage under this
plan, the Penalty for Late Entrants provision will not apply to them with
regard to dental coverage provided their coverage under the other plan ends
due to one of the following events: (a) termination of your spouse’s
employment; (b) loss of eligibility under your spouse’s plan; (c) divorce; (d)
death of your spouse; or (e) termination of the other plan.
But you must enroll your spouse or eligible dependent children in the dental
coverage under this plan within 30 days of the date that any of the events
described above occur.
00283190/00063.0/A /T68069/9999/0001
P. 12
In addition, the Penalty for Late Entrants provision for dental coverage will
not apply to your spouse or eligible dependent children if: (a) you are under
legal obligation to provide dental coverage due to a court-order; and (b) you
enroll them in the dental coverage under this plan within 30 days of the
issuance of the court-order.
B200.0749
When Dependent In order for your dependent coverage to begin you must already be insured
Coverage Starts for employee coverage or enroll for employee and dependent coverage at
the same time. Subject to the "Exception" stated below and to all of the
terms of this plan, the date your dependent coverage starts depends on
when you elect to enroll your initial dependents and agree to make any
required payments.
If you do this on or before your eligibility date, the dependent’s coverage is
scheduled to start on the later of the first of the month which coincides with
or next follows your eligibility date and the date you become insured for
employee coverage.
If you do this within the enrollment period, the coverage is scheduled to start
on the later of the first of the month which coincides with or next follows the
date you sign the enrollment form; and the date you become insured for
employee coverage.
If you do this after the enrollment period ends, each of your initial
dependents is a late entrant and is subject to any applicable late entrant
penalties. The dependent’s coverage is scheduled to start on the first of the
month which coincides with or next follows the date you sign the enrollment
form.
Once you have dependent coverage for your initial dependents, you must
notify us when you acquire any new dependents and agree to make any
additional payments required for their coverage.
If you do this within 31 days of the date the newly acquired dependent
becomes eligible, the dependent’s coverage will start on the date the
dependent first becomes eligible. If you fail to notify us on time, the newly
acquired dependent, when enrolled, is a late entrant and is subject to any
applicable late entrant penalties. The late entrant’s coverage is scheduled to
start on the date you sign the enrollment form.
B489.0055
Exception
If a dependent, other than a newborn child, is confined to a hospital or other
health care facility; or is home-confined; or is unable to carry out the normal
activities of someone of like age and sex on the date his dependent benefits
would otherwise start, we will postpone the effective date of such benefits
until the day after his discharge from such facility; until home confinement
ends; or until he resumes the normal activities of someone of like age and
sex.
B200.0692
00283190/00063.0/A /T68069/9999/0001
P. 13
Newborn Children
We cover your newborn child for dependent benefits, from the moment of his
or her birth if: (a) you are already covered for dependent child coverage
when the child is born; or (b) you enroll the child for dependent coverage
within 31 days of the child’s birth and agrees to make any required premium
payments within 31 days of the date the child is born. If you fail to do this,
once the child is enrolled, the child is a late entrant, is subject to any
applicable late entrant penalties, and will be covered as of the date you sign
the enrollment form.
B489.0008
When Dependent Dependent coverage ends for all of your dependents when your coverage
Coverage Ends ends. But if you die while insured, we’ll automatically continue dependent
benefits for those of your dependents who were insured when you died.
We’ll do this for six months at no cost, provided: (a) the group plan remains
in force; (b) the dependents remain eligible dependents; and (c) in the case
of a spouse, the spouse does not remarry. And we’ll also automatically cover
a newborn child born to your spouse within six months of your death. But
any such newborn child’s coverage will end six months from the date you
died. There is no cost for this coverage. If a surviving dependent elects to
continue his or her dependent benefits under this plan’s "Federal
Continuation Rights" provision, or under any other continuation provision of
this plan, if any, this free continuation period will be provided as the first six
months of such continuation. Premiums required to be paid by, or on behalf
of a surviving dependent will be waived for the first six months of
continuation, subject to restrictions (a), (b) and (c) above. After the first six
months of continuation, the remainder of the continuation period, if any, will
be subject to the premium requirements, and all of the terms of the "Federal
Continuation Rights" or other continuation provisions.
Dependent coverage also ends for all of your dependents when you stop
being a member of a class of employees eligible for such coverage. And it
ends when this plan ends, or when dependent coverage is dropped from this
plan for all employees or for an employee’s class.
If you are required to pay all or part of the cost of dependent coverage, and
you fail to do so, your dependent coverage ends. It ends on the last day of
the period for which you made the required payments, unless coverage ends
earlier for other reasons.
An individual dependent’s coverage ends when he or she stops being an
eligible dependent. This happens to a child at 12:01 a.m. on the date the
child attains this coverage’s age limit, when he or she marries, or when a
step-child is no longer dependent on you for support and maintenance. It
happens to a spouse when a marriage ends in legal divorce or annulment.
Read this plan carefully if dependent coverage ends for any reason.
Dependents may have the right to continue certain group benefits for a
limited time.
B489.0033
00283190/00063.0/A /T68069/9999/0001
P. 14
DENTAL HIGHLIGHTS
This page provides a quick guide to some of the Dental Expense Insurance
plan features which people most often want to know about. But it’s not a
complete description of your Dental Expense Insurance plan. Read the
following pages carefully for a complete explanation of what we pay, limit and
exclude.
PPO Benefit Year Cash Deductible for Non-Orthodontic Services
For Group I Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
For Group II and III Services . . . . . . . . . . . . . . . . . . . . . . . . . . . $100.00
for each covered person
Non-PPO Benefit Year Cash Deductible for
Non-Orthodontic Services
For Group I Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
For Group II and III Services . . . . . . . . . . . . . . . . . . . . . . . . . . . $100.00
for each covered person
B497.0070
Payment Rates for Services Furnished by a Preferred Provider:
For Group I Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100%
For Group II Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100%
For Group III Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60%
Payment Rates for Services Not Furnished by a Preferred Provider:
For Group I Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100%
For Group II Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80%
For Group III Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50%
B497.0088
Benefit Year Payment Limit for Non-Orthodontic Services
For Group I, II and III Services . . . . . . . . . . . . . . . . . . . Up to $1,000.00
Note: A covered person may be eligible for a rollover of a portion of his or
her unused Benefit Year Payment Limit for Non-Orthodontic Services. See
"Rollover of Benefit Year Payment Limit for Non-Orthodontic Services" for
details.
B497.1431
Group Enrollment A group enrollment period is held each year from March 1st to March 31st .
Period During this period, you may elect to enroll in dental insurance under this
plan. Coverage starts on the April 1st that next follows the date of
enrollment. You and your eligible dependents are not subject to late entrant
penalties if you enroll during the group enrollment period.
B497.1014
00283190/00063.0/A /T68069/9999/0001
P. 15
DENTAL EXPENSE INSURANCE
This insurance will pay many of a covered person’s dental expenses. We
pay benefits for covered charges incurred by a covered person. What we
pay and terms for payment are explained below.
B498.0007
DentalGuard Preferred - This Plan’s Dental
Preferred Provider Organization
This plan is designed to provide high quality dental care while controlling the
cost of such care. To do this, the plan encourages a covered person to seek
dental care from dentists and dental care facilities that are under contract
with Guardian’s dental preferred provider organization (PPO), which is called
DentalGuard Preferred.
The dental PPO is made up of preferred providers in a covered person’s
geographic area. Use of the dental PPO is voluntary. A covered person may
receive dental treatment from any dental provider he or she chooses. And he
or she is free to change providers anytime.
This plan usually pays a higher level of benefits for covered treatment
furnished by a preferred provider. Conversely, it usually pays less for
covered treatment furnished by a non-preferred provider.
When an employee enrolls in this plan, he or she and his or her dependents
receive a dental plan ID card and information about current preferred
providers.
A covered person must present his or her ID card when he or she uses a
preferred provider. Most preferred providers prepare necessary claim forms
for the covered person, and submit the forms to us. We send the covered
person an explanation of this plan’s benefit payments, but any benefit
payable by us is sent directly to the preferred provider.
What we pay is based on all of the terms of this plan. Please read this plan
carefully for specific benefit levels, deductibles, payment rates and payment
limits.
A covered person may call the Guardian at the number shown on his or her
ID card should he or she have any questions about this plan.
B498.0151
Covered Charges
If a covered person uses the services of a preferred provider, covered
charges are the charges listed in the fee schedule the preferred provider has
agreed to accept as payment in full, for the dental services listed in this
plan’s List of Covered Dental Services.
If a covered person uses the services of a non-preferred provider, covered
charges are reasonable and customary charges for the dental services listed
in this plan’s List of Covered Dental Services.
00283190/00063.0/A /T68069/9999/0001
P. 16
Covered Charges (Cont.)
To be covered by this plan, a service must be: (a) necessary; (b) appropriate
for a given condition; and (c) included in the List of Covered Dental Services.
We may use the professional review of a dentist to determine the appropriate
benefit for a dental procedure or course of treatment.
By reasonable, we mean the charge is the dentist’s usual charge for the
service furnished. By customary, we mean the charge made for the given
dental condition isn’t more than the usual charge made by most other
dentists. But, in no event will the covered charge be greater than the 90th
percentile of the prevailing fee data for a particular service in a geographic
area.
When certain comprehensive dental procedures are performed, other less
extensive procedures may be performed prior to, at the same time or at a
later date. For benefit purposes under this plan, these less extensive
procedures are considered to be part of the more comprehensive procedure.
Even if the dentist submits separate bills, the total benefit payable for all
related charges will be limited to the maximum benefit payable for the more
comprehensive procedure. For example, osseous surgery includes the
procedure scaling and root planing. If the scaling and root planing is
performed one or two weeks prior to the ossesous surgery, we may only pay
benefits for the ossesous surgery.
We only pay benefits for covered charges incurred by a covered person
while he or she is insured by this plan. A covered charge for a crown, bridge
or cast restoration is incurred on the date the tooth is initially prepared. A
covered charge for any other dental prosthesis is incurred on the date the
first master impression is made. A covered charge for root canal treatment is
incurred on the date the pulp chamber is opened. All other covered charges
are incurred on the date the services are furnished. If a service is started
while a covered person is insured, we’ll only pay benefits for services which
are completed within 31 days of the date his or her coverage under this plan
ends.
B498.0318
Alternate Treatment
If more than one type of service can be used to treat a dental condition, we
have the right to base benefits on the least expensive service which is within
the range of professionally accepted standards of dental practice as
determined by us. For example, in the case of bilateral multiple adjacent
teeth, or multiple missing teeth in both quadrants of an arch, the benefit will
be based on a removable partial denture. In the case of a composite filling
on a posterior tooth, the benefit will be based on the corresponding amalgam
filling benefit.
00283190/00063.0/A /T68069/9999/0001
P. 17
Proof of Claim
So that we may pay benefits accurately, the covered person or his or her
dentist must provide us with information that is acceptable to us. This
information may, at our discretion, consist of radiographs, study models,
periodontal charting, narratives or other diagnostic materials that document
proof of claim and support the necessity of the proposed treatment. If we
don’t receive the necessary information, we may pay no benefits, or
minimum benefits. However, if we receive the necessary information within
15 months of the date of service, we will redetermine the covered person’s
benefits based on the new information. Failure to furnish such proof within
such time will not invalidate or reduce any claim if it will be shown not to
have been reasonably possible to furnish such proof and that such proof was
furnished as soon as was reasonably possible.
B498.0313
Pre-Trea

Tekmark Global Solutions Employee Benefit Plan Summary of Plan

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