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Table Of Contents

Introduction
How to Use this Document
Information about Defined Terms
Fraud and Abuse
Your Contribution to the Benefit Costs
Customer Service and Claims Submittal
Section 1: What's Covered--Benefits
Accessing Benefits
Copayment/Coinsurance
Eligible Expenses
Notification Requirements
Payment Information
Lifetime Maximum*
Benefit Information
1. Ambulance Services - Emergency only
2. Dental Services and Oral Care Surgery:
3. Durable Medical Equipment
4. Emergency Health Services
6. Home Health Care
10. Injections received in a Physician's Office
12. Mental Health Services
13. Nutritional Counseling
14. Ostomy and Urinary Catheter Supplies
15. Outpatient Surgery, Diagnostic and Therapeutic Services
17. Professional Fees for Surgical and Medical Services
18. Prosthetic Devices
19. Reconstructive Procedures
20. Rehabilitation Services - Outpatient Therapy
21. Skilled Nursing Facility
23. Substance Use Disorder Services
24. Transplantation Services
25. Urgent Care Center Services
26. Wigs
Section 2: What's Not Covered-- Exclusions
How We Use Headings in this Section
We Do Not Pay Benefits for Exclusions
A. Alternative Treatments
B. Comfort or Convenience
C. Dental
I. Nutrition
J. Physical Appearance
K. Providers
L. Reproduction
M. Services Provided under Another Plan
N. Transplants
O. Travel
P. Vision and Hearing
Q. All Other Exclusions
Section 3: Obtaining Benefits
Benefits
Benefits for Health Services from Non- Network Providers
Emergency Health Services
Section 4: When Coverage Begins
How to Enroll
If You Are Hospitalized When Your Coverage Begins
Who is Eligible for Coverage
Dependent
When to Enroll and When Coverage Begins
DCH Surcharge Policy
Enrollment Periods
Plan Options
Enrolling A Newly Eligible Dependent
When Coverage Begins
Adding Dependents
Within 31 days of the child becoming disabled
How to Request a Change
General Information about When Coverage Ends
Events Ending Your Active Coverage
Plan Membership
Near Retirement
Eligibility – to continue health insurance and draw an annuity
Applying for Coverage Continuation
Continuing Dependent Coverage at Your Death
Making Changes to Your Retiree Coverage
Dropping Your Retiree Coverage
Qualifying Events
qualifying event
Changes Permitted Without A Qualifying Event
Retiree Option Change Period
If You Return to Active Service
Frequently asked Medicare Questions
Filing a Claim for Benefits
Urgent Claims that Require Immediate Action
How to Appeal a Claim Decision
Appeals Determinations
Urgent Claim Appeals that Require Immediate Action
Voluntary External Review Program
How COB Works
How to Tell Which Plan is Primary
If You Have Dual Plan Coverage
Other Forms of Duplicated Benefits
If You Leave Your Job
In the Event of an Active Employee’s Death
Continuation of Coverage
Plan Document
Relationship with Providers
Your Relationship with Providers
Incentives to You
Interpretation of Benefits
Administrative Services
Clerical Error
Information and Records
Examination of Covered Persons
Workers' Compensation not Affected
Subrogation and Reimbursement
Refund of Overpayments
Limitation of Action
Section 11: Your Rights and Responsibilities
Section 13: Glossary of Defined Terms
Riders, Amendments, Notices
Outpatient Prescription Drug Rider
Benefits for Outpatient Prescription Drug Products
Coverage Policies and Guidelines
Identification Card (ID Card) - Network Pharmacy
Limitation on Selection of Pharmacies
Special Programs
Member Rights and Responsibilities
UnitedHealthcare Disclaimer
When a Brand-name Drug Becomes Available as a Generic
Supply Limits
Progression Rx Program Requirements
Clinical Appeal Process
Coordination of Benefits (COB)
What You Must Pay
Understanding Tiers
How often will prescription medications change tiers?
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Published by: Courage Ethics on Nov 08, 2011
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