2007 Certificate of Coverage and Pharmacy Rider Reference Guide. New York

Transcription

1 2007 Certificate of Coverage and Pharmacy Rider Reference Guide New York

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3 Table of Contents A. Strategic Vision A-1 B. New Clinical Trials B-1 Congenital Heart Disease Surgery B-2 Diabetes Services B-3 Ostomy Supplies B-4 Pharmaceutical Products Outpatient B-5 Preventive Care B-6 Scopic Procedures - Outpatient & Therapeutic B-7 C. Changes Ambulance C-1 Dental Accidental Injury, Congenital Disease and Anomaly C-2 Durable Medical Equipment C-3 Emergency Services C-4 Home Health Care C-5 Hospice C-6 Hospital Inpatient C-7 Injections Physician s Office C-8 Lab and Xray Outpatient C-9 Lab/Xray CT, MRI Outpatient C-10 MH/SA Outpatient C-11 MH/SA Inpatient C-12 Physician Office Visit C-13 Prosthetic Devices C-14 Reconstructive Procedures C-15 Rehab Services Outpatient C-16 Surgery Outpatient C-17 Therapeutic Treatments C-18 Transplant Services C-19 Urgent Care C-20 Vision Exam C Certificate of Coverage Reference Guide

4 D. Language Clarifications Dental Care D-1 Physician Fees Surgical and Medical D-2 Pregnancy D-3 Skilled Nursing Facility D-4 E. Pre-service Notification E-1 F. Exclusions Highlights of Changes Alternative Treatments F-1 Physical Appearance F-2 Procedures & Treatments F-3 G. Pharmacy Optimal Benefit G-2 Limited Mail Order G-3 ProgressionRx G-4 Coordination of Benefits G-5 Therapeutic Equivalents G Certificate of Coverage Reference Guide

5 A. Strategic Vision Introducing the UnitedHealthcare 2007 Certificate of Coverage and Pharmacy Rider Delivering new opportunities in health care affordability, quality, usability and accessibility With the new 2007 Certificate of Coverage (COC) and Pharmacy Rider, UnitedHealthcare has made several improvements for our customers and members. The 2007 COC provides coverage to our members that supports overall health and wellness, as well as more ways that help our customers manage costs. The 2007 COC supports and reinforces UnitedHealthcare s Total Affordability Management SM approach to health care, focusing on our core capabilities. Through this approach, UnitedHealthcare offers plans that support consumer-driven health care; network advantages through utilization of network cost benefits, the UnitedHealth Premium designation program to assist in the selection of quality and efficient physicians and facilities, and United Resource Networks for access to leading facilities and services that focus on complex or rare medical conditions; and proactive care, including care and disease management programs. Some of the COC s new and enhanced coverage features that will be used in most UnitedHealthcare standard plans include: Coverage for medical costs related to participation in certain clinical trials Coverage for ostomy supplies Hospice care with no day limit Expanded ambulance service for approved non-emergency transportation 2007 Certificate of Coverage Reference Guide A-1

6 Access to a more comprehensive Centers of Excellence network for complex treatments through United Resource Networks (such as congenital heart disease, transplants, and cancer) Expanded optional buy-up coverage options for most groups of 300 or more with underwriting approval We believe that customers will experience more ways that help control costs with these new COC features: Addition of new Value plans that offer lower pricing without affecting member annual deductibles or copays Member pre-service notification requirements for certain services Equalized cost-sharing on some services available in either a physician s office, urgent care center or an outpatient facility In addition to the above changes, the 2007 COC continues to offer a wide selection of plan designs from consumer-driven health plans to traditional benefits. It also contains format improvements for easy readability and simplified descriptions. The benefit information provided represents the UnitedHealthcare national standards. State-specific regulations will always override these standards. Some local and customer-specific plans may vary from these standards. We hope you find this easy-to-follow instructional booklet on the new 2007 COC helpful and informative. Timing of implementation for the 2007 COC will vary by state. Most states will have the COC implemented during 2007; however, some states will be implemented in Contact your UnitedHealthcare representative for the most up-to-date estimate of implementation timing for your state. A Certificate of Coverage Reference Guide

7 B. New Clinical Trials Benefit: Coverage for clinical trials related to the treatment of cancer, cardiovascular, and musculoskeletal surgery of the spine, hip and knee. Clinical trials must be approved trials sponsored by a nationally recognized center detailed in the Certificate of Coverage. Deductible and coinsurance apply. Rationale: This new benefit category supports UnitedHealthcare s commitment to evidence-based medicine research and the Clinically Integrated Network initiatives. Pre-service Notification requirements: Choice: Network services Choice Plus: Network and Non-Network services PPO: Network and Non-Network services Notification Requirement: As soon as the possibility of participation in clinical trial arises Covered person is responsible for notification of Network and Non- Network benefits Non-notification Penalty: No benefits will be paid 2007 Certificate of Coverage Reference Guide B-1

8 Congenital Heart Disease Surgery Benefit: This is a new benefit category, not a change in benefit coverage and it adds access to new United Resource Networks Centers of Excellence facilities. Coverage for complex congenital heart disease (CHD) surgery. Deductible and coinsurance apply. Network no maximum. Non-Network limited to $30,000 per surgery. Rationale: This new benefit category promotes the use of Centers of Excellence to facilitate consistent care standards that can result in savings for our consumers. Choice: Not Applicable Choice Plus: Non-Network services PPO: Network and Non-Network services Notification Requirement: As soon as the possibility of CHD surgery arises Covered person is responsible for an additional notification 24 hours before Non-Network scheduled admissions; however, covered person will not be penalized if the second notification requirement is not made Non-notification Penalty: Coverage is reduced to 50% of eligible expenses. B Certificate of Coverage Reference Guide

9 Diabetes Services Benefit: This is a new benefit category, not a change in benefit coverage. Coverage for diabetes self-management education, diabetic eye exams, diabetic foot care, insulin pump and diabetic supplies. Coverage continues to be under applicable benefit categories, for example, eye exams would be covered under the physician office visit. The benefit level of the applicable benefit categories apply. Rationale: This new benefit category is added in response to consumer requests to simplify locating and understanding Diabetic Services. DME services over $1,000 only Choice: Not Applicable Choice Plus: Non-Network services only PPO: Network and Non-Network services Notification Requirement: Prior to obtaining equipment Non-notification Penalty: Benefits will be reduced to 50% of eligible expenses 2007 Certificate of Coverage Reference Guide B-3

10 Ostomy Supplies Benefit: Coverage limited to pouches, face plates, belts, irrigation sleeves, bags and ostomy irrigation catheters, skin barriers. Limited to $2,500 per calendar year, combined Network and Non-Network. Deductible and coinsurance apply. Rationale: This new benefit coverage is included in response to requests by customers and brokers. Choice: Not Applicable Choice Plus: Not Applicable PPO: Not Applicable Notification Requirement Not Applicable Non-notification Penalty: Not Applicable B Certificate of Coverage Reference Guide

11 Pharmaceutical Products Outpatient Benefit: This is a new benefit category. Pharmaceutical products administered on an outpatient basis in a hospital, alternate facility, Physician s office, or a covered person s home are covered. Benefits under this section do not include medications that are typically available by prescription order or refill at a pharmacy. Deductible and coinsurance apply. If the service is provided in the Physician s office and the plan design includes an office visit copayment, these services are not covered by the office visit copayment. The covered person will pay both the office visit copayment and the deductible and coinsurance. Pharmaceutical products in this category may include antibiotic injections, IV infusions like Remicade, nitroglycerine tablets, chemotherapy drugs, and Factor VIII. This does not include allergy injections (Physician Office Services) or immunization (Preventive Care Services). Rationale: This new benefit category provides the opportunity to standardize the cost for these services regardless of the place of service. Pre-service Notification Choice: Not Applicable Choice Plus: Not Applicable PPO: Not Applicable Notification Requirement: Not Applicable Non-notification Penalty: Not Applicable 2007 Certificate of Coverage Reference Guide B-5

12 Preventive Care Services Benefit: This is a new benefit category, not a change in benefit coverage. Covered services include, but are not limited to: immunizations, flu shots, mammograms, pap smears, scopic screenings, screening lab work and x-rays, bone density testing, and other testing. Some services require preventive care diagnosis codes to be covered as preventive care services (e.g., scopic screenings, lab work and x-rays). Most plan designs: services are subject to office visit copayment. Some plan designs: apply deductible and coinsurance. Most Health Savings Account (HSA) plans and other plans cover preventive care services at 100%. Non-Network services are excluded and not covered, except where prohibited by regulation. Rationale This new benefit category is added in response to consumer requests to simplify finding and understanding Preventive Care Services coverage. Choice: Not Applicable Choice Plus: Not Applicable PPO: Not Applicable Notification Requirement Not Applicable Non-notification Penalty: Not Applicable B Certificate of Coverage Reference Guide

13 Scopic Procedures Outpatient & Therapeutic Benefit: This is a new benefit category, not a change in benefit coverage. Diagnostic scopic procedures are those for visualization, biopsy and polyp removal. Examples include colonoscopy, sigmoidoscopy, and endoscopy. 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, hysteroscopy. If a diagnostic scopic procedure is billed with a preventive care diagnosis code, services will be processed under the Preventive Care Services section. Deductible and coinsurance apply. If the service is provided in the Physician s office and the plan design includes an office visit copayment, these services are not covered by the office visit copayment. The covered person will pay both the office visit copayment and the deductible and coinsurance. Rationale: This new benefit category promotes clarity and better understanding of the benefits, and standardizes the cost for those services regardless of the place of service. Choice: Not Applicable Choice Plus: Not Applicable PPO: Not Applicable Notification Requirement: Not Applicable Non-notification Penalty: Not Applicable 2007 Certificate of Coverage Reference Guide B-7

14 C. Changes Ambulance Benefit Change: Coverage expanded to include approved non-emergency transport between facilities and from a non-network hospital to a network hospital that provides a higher level of care not available at the original hospital. Deductible and coinsurance apply. Rationale: Coverage is expanded to cover non-emergency transport between facilities to support obtaining the appropriate level of care for consumers. Non-emergent Transport only Choice: Network services Choice Plus: Network and Non-Network services PPO: Network and Non-Network services Notification Requirement: Within 5 business days before or as soon as reasonably possible prior to the service being performed for nonemergent air and ground transport Covered person is responsible for notification Non-notification Penalty: No benefits will be paid C Certificate of Coverage Reference Guide

15 Dental Services Accidental Injury, Congenital Disease and Anomaly Benefit: Coverage limited to sound, natural teeth Benefit limit: None Benefits are available only for dental services provided within 12 months of the accident Deductible and coinsurance apply Choice: Network services Choice Plus: Network and Non-Network services PPO: Network and Non-Network services Notification Requirement: within 5 business days or as soon as reasonably possible prior to receiving post emergency treatment Covered person is responsible for notification Non-notification Penalty: Coverage is reduced to 50% of eligible expenses 2007 Certificate of Coverage Reference Guide C-2

16 Durable Medical Equipment (DME) Benefit: Benefit provides a single purchase (including repair and replacement) of a type of DME once every three years. Network and Non-Network combined benefit limit of $2,500 per year. Limit includes repair and replacement. Rationale: The benefit changes are designed to standardize and simplify benefits. Required for DME over $1,000 before the purchase of the item Choice: Not Applicable Choice Plus: Non-Network services only PPO: Network and Non-Network services Non-notification Penalty: No Benefits will be paid C Certificate of Coverage Reference Guide

17 Emergency Room Health Services Benefit Change: The annual deductible will not be waived on deductible / coinsurance plan designs. The emergency room copayment is waived if admitted to the hospital through the emergency room. Non-Network providers will be paid at the Network benefit level. Rationale: The change is to align cost-sharing and benefit standards across all lines of business. Choice: Not Applicable Choice Plus: Non-Network services only Options PPO: Network and Non-Network services Notification Requirement: If admitted to the hospital following outpatient emergency treatment, notification requirement for inpatient admission must be received within 1 business day or on the same day of admission if reasonably possible 2007 Certificate of Coverage Reference Guide C-4

18 Home Health Care Benefit Change: Home IV infusion services do not count toward the Home Health visit limit. Home Health Care is limited to 60 visits per year for combined Network and Non-Network. Rationale: Preserve the Home Health Care benefit to facilitate appropriate inpatient discharge and admission avoidance. Choice: Not Applicable Choice Plus: Non-Network services only PPO: Network and Non-Network services Notification Requirement: Within 5 business days prior to receiving services or as soon as reasonably possible Non-notification Penalty: Coverage is reduced to 50% of eligible expenses C Certificate of Coverage Reference Guide

19 Hospice Benefit Change: Unlimited, no day limit for Network and Non-Network. Deductible and coinsurance apply. Rationale: Coverage limit was eliminated to remove any barriers to hospice care. Inpatient admission only Choice: Not Applicable Choice Plus: Non-Network services only PPO: Network and Non-Network services Notification Requirement: Within 5 business days or as soon as reasonably possible prior to admission Non-notification Penalty: Coverage is reduced to 50% of eligible expenses 2007 Certificate of Coverage Reference Guide C-6

20 Hospital Inpatient Stay Benefit Change: An additional Pre-Service Notification requirement has been added for the covered person. Rationale: This Non-Network notification facilitates access to Care Management resources and supports appropriate inpatient discharge planning. Choice: Not Applicable Choice Plus: Non-Network services only PPO: Network and Non-Network services Notification Requirement: Within 5 business days for scheduled admissions. Notification is required within 24 hours of admission or as soon as reasonably possible for non-scheduled admissions (including emergency admissions) Covered person is responsible to make an additional notification 24 hours before Non-Network admission; however, covered person will not be penalized if the second notification is not made Non-notification Penalty: Coverage is reduced to 50% of eligible expenses if first notification requirement is not made C Certificate of Coverage Reference Guide

21 Injections in a Physician s Office Benefit Change: The benefit category, not injection coverage, has been eliminated. Allergy injections will be covered under the Physician s Office Services benefit and will incur the lesser of the Physician s office visit copayment or eligible expenses. Immunizations will be covered under the Preventive Care Services benefit. All other injections will be covered under the Pharmaceutical Products benefit. Deductible and coinsurance apply. Rationale: This benefit category was eliminated to reduce confusion and promote clarity and better understanding of the benefits Certificate of Coverage Reference Guide C-8

22 Lab, X-ray and Diagnostics Outpatient Benefit Change: This is a new benefit category, not a change in benefit coverage. Rationale: The Outpatient Surgery, Diagnostic and Therapeutic Services category was eliminated and broken down into individual benefit categories to reduce confusion and provide flexibility for creating benefit designs. Choice: Not Applicable Choice Plus: Not Applicable PPO: Not Applicable Notification Requirement: Not Applicable Non-notification Penalty: Not Applicable C Certificate of Coverage Reference Guide

23 Lab and X-ray CT, MRI, MRA, PET, Nuclear Medicine Outpatient Benefit Change: This is a new benefit category, not a new benefit coverage. Deductible and coinsurance apply. If the service is performed in a Physician s office or urgent care facility and the plan design includes an office visit or urgent care copayment, these services are not covered by the office visit or urgent care copayment. The covered person will pay both the office visit or urgent care copayment and deductible and coinsurance. Rationale: The Outpatient Surgery, Diagnostic and Therapeutic Services category was eliminated and broken down into individual benefit categories to reduce confusion and provide flexibility for creating benefit designs. Choice: Not Applicable Choice Plus: Not Applicable PPO: Not Applicable Notification Requirement Not Applicable Non-notification Penalty: Not Applicable 2007 Certificate of Coverage Reference Guide C-10

24 Mental Health/Substance Abuse Outpatient Benefit: Mental Health benefit limit continues to be 30 visits per calendar year, combined Network and Non-Network. Substance Abuse benefit limit continues to be 60 visits per calendar year, combined Network and Non-Network. Up to 20 of these are available for Covered Persons who are family members of the person suffering from the disease of alcoholism, substance abuse or chemical dependency. Individual and group visits will apply the Specialist Office Visit copayment or deductible/coinsurance. Choice: Network services Choice Plus: Network and Non-Network services PPO: Network and Non-Network services Notification Requirement: Prior authorization through the Mental Health/Substance Abuse Designee must be obtained Covered person is responsible for notification Non-notification Penalty: No Benefits will be paid C Certificate of Coverage Reference Guide

25 Mental Health/Substance Abuse Inpatient Benefit: Mental health benefit limit continues to be 30 inpatient days per calendar year, combined Network and Non-Network. Substance abuse benefit limit continues to be 7 days for detoxification and 30 inpatient days for rehabilitation per calendar year, combined Network and Non-Network. Two visits of partial hospitalization are equal to one inpatient day. Deductible and coinsurance apply. Choice: Network services Choice Plus: Network and Non-Network services PPO: Network and Non-Network services Notification Requirement: Prior authorization through the Mental Health/Substance Abuse Designee must be obtained Covered person is responsible for notification Non-notification Penalty: No Benefits will be paid 2007 Certificate of Coverage Reference Guide C-12

26 Physician s Office Services Sickness and Injury Benefit Change: Physician Office Services refer only to Covered Health Services for the diagnosis and treatment of a sickness or injury. Physician Office Services for Covered Health Services for preventive medical care has been moved to a separate benefit category. Most plans: services subject to a copayment. These include, but are not limited to: physician evaluation and management, allergy shots, blood sugar checks, high blood pressure checks and others. If the eligible expenses are less than the office visit copayment, the covered person will be responsible for the lesser amount. If outpatient surgery, major diagnostics services (i.e., CT, MRI, and others), therapeutic services, or pharmaceutical products are administered in a Physician s office and the plan design includes an office visit copayment, these services are not covered by the office visit copayment. The covered person will pay both the office visit copayment and the deductible and coinsurance for the other services. Rationale: The Physician Office Service category has been simplified to promote clarity and better understanding of the benefits and to standardize the cost for those services available in the Physician s office, urgent care or outpatient facilities. Choice: Not Applicable Choice Plus: Not Applicable PPO: Not Applicable Notification Requirement: Not Applicable Non-notification Penalty: Not Applicable C Certificate of Coverage Reference Guide

27 Prosthetic Devices Benefit Change: Benefits are limited to a single purchase of a type of device once every three years (this is a change for Small Business only). The limit of $2,500 combined Network and Non-Network remains the same. Limit includes repairs and replacements of the devices. Deductible and coinsurance apply. Rationale: The benefit changes are designed to standardize and simplify benefits. Choice: Not Applicable Choice Plus: Not Applicable PPO: Not Applicable Notification Requirement: Not Applicable Non-notification Penalty: Not Applicable 2007 Certificate of Coverage Reference Guide C-14

28 Reconstructive Procedures Benefit Change: Breast reduction surgery is a standard exclusion except as required by the Women s Health and Cancer Rights Act of Deductible and coinsurance apply. Rationale: The benefit change is designed to reduce confusion about the coverage of breast reduction surgery. Choice: Not Applicable Choice Plus: Non-Network services only PPO: Network and Non-Network services Notification Requirement: Within 5 business days for scheduled admissions or 1 business day for non-scheduled admissions or as soon as reasonably possible Covered person is required to make an additional notification 24 hours before Non-Network scheduled admissions; however, covered person will not be penalized if the second notification requirement is not made Non-notification Penalty: Coverage is reduced to 50% of eligible expenses C Certificate of Coverage Reference Guide

29 Rehabilitation Services Outpatient Benefit Change: Benefit category has been changed to include chiropractic treatment and post-cochlear implant aural therapy. Standard benefit limits are combined for Network and Non-Network visits per year: 20 visits for Physical Therapy 20 visits for Occupational Therapy 20 visits for Speech Therapy 20 visits for Pulmonary Therapy 36 visits for Cardiac Rehabilitation Therapy Unlimited visits for Chiropractic Therapy 30 visits for Post-Cochlear Implant Aural Therapy Rationale: The benefit changes promote clarity and better understanding of the benefits, and standardizes the cost of these services regardless of the place of service. Chiropractic services only Choice: Not Applicable Choice Plus: Non-Network services only PPO: Network and Non-Network services Notifications Requirement: Within 5 business days prior to receiving services Non-notification Penalty: Coverage is reduced to 50% of eligible expenses 2007 Certificate of Coverage Reference Guide C-16

30 Surgery Outpatient Benefit Change: If the service is performed in a Physician s office or urgent care facility and the plan design includes an office visit or urgent care copayment, these services are not covered by the office visit or urgent care copayment. The covered person will pay both the copayment and the deductible and coinsurance for the surgery. Rationale: The benefit change promotes clarity and better understanding of the benefits, and standardizes the cost for these services regardless of the place of service. Choice: Not Applicable Choice Plus: Not Applicable PPO: Not Applicable Notification Requirement: Not Applicable Non-notification Penalty: Not Applicable C Certificate of Coverage Reference Guide

31 Therapeutic Treatments Outpatient (Dialysis, Chemotherapy and Radiation Oncology) Benefit Change: If the service is performed in a Physician s office or urgent care facility and the plan design includes an office visit or urgent care copayment, these services are not covered by the office visit or urgent care copayment. The covered person will pay both the copayment and the deductible and coinsurance for the treatment. Deductible and coinsurance apply in addition to any office copayment. Therapeutic treatments include, but are not limited to: dialysis, intravenous chemotherapy or other intravenous infusion therapy, radiation oncology and hyperbaric oxygen therapy. Rationale: The benefit change promotes clarity and better understanding of the benefits, and standardizes the cost for these services regardless of the place of service. Dialysis only Choice: Not Applicable Choice Plus: Non-Network services only PPO: Network and Non-Network services Notification Requirement: Within 5 business days for scheduled services. Notification is required within 1 business day or as soon as reasonably possible for non-scheduled services Non-notification Penalty: Coverage is reduced to 50% of eligible expenses 2007 Certificate of Coverage Reference Guide C-18

32 Transplant Services Benefit Change: An additional pre-service notification has been added - within 24 hours of Non-Network inpatient admission for scheduled procedures. Benefits have not changed. Covered transplants include: cornea, kidney, pancreas, kidney/pancreas, liver, heart, lung, heart/lung, small bowel, liver/small bowel and bone marrow at an affiliated United Resource Networks (U.R.N.) designated facility. Non-Network benefits are limited to $200,000 per transplant. Rationale: The Non-Network notification facilitates access to U.R.N. and Care Management resources and supports appropriate inpatient discharge planning. Pre-service Notification Requirements: Choice: Network services Choice Plus: Network and Non-Network services PPO: Network and Non-Network services Notification Requirement: U.R.N. must review the case and designate the facility in which the transplant will be conducted to receive benefits at a Network level Additional notification is required within 24 hours of Non-Network inpatient admission for scheduled procedures U.R.N. does not require cornea transplants to be performed at a designated facility. Benefits are available for cornea transplants through a Network provider at a Network facility If U.R.N. designates a Non-Network facility, benefits will pay at the Network level Covered person is responsible for notification Non-notification Penalty: Coverage is reduced to 50% of eligible expenses C Certificate of Coverage Reference Guide

33 Urgent Care Benefit Change: If outpatient surgeries, rehabilitation services, major diagnostic services (i.e., CT, MRI and others), pharmaceutical services and outpatient therapeutic service are performed at an urgent care facility and the plan design includes an urgent care copayment, these services are not covered by the copayment. The covered person will pay both the copayment and the deductible and coinsurance for the specific services. Urgent Care Services are subject to the urgent care copayment, or the deductible and coinsurance apply. Rationale: The changes promote clarity and better understanding of the benefits and standardize the cost for those services available in the Physician's office, urgent care or outpatient facilities. Choice: Not Applicable Choice Plus: Not Applicable PPO: Not Applicable Notification Requirement Not Applicable Non-notification Penalty: Not Applicable 2007 Certificate of Coverage Reference Guide C-20

34 Vision Exam (Replaces Eye Exam Category) Benefit Change: Benefits include routine assessment of vision with a refraction exam, limited to one routine eye exam (including refraction exam) every other year by a Network provider. Eye examinations required for the diagnosis and treatment of sickness or injury are provided under the Physician Office Services benefit. Non-Network refraction eye exams are not covered. Benefits are not eligible for charges connected to the purchase or fitting of eyeglasses or contact lenses. Benefit pays as coverage of Physician Office Services. Rationale: The name of the benefit category is changed from Eye Exam to Vision Exam to reduce confusion about coverage. Choice: Not Applicable Choice Plus: Not Applicable PPO: Not Applicable Notification Requirement Not Applicable Non-notification Penalty: Not Applicable C Certificate of Coverage Reference Guide

35 D. Language Clarifications Dental Care Benefit Clarification: Dental care is excluded, except as necessary for the direct treatment of a covered medical condition (transplant preparation, prior to initiation of immunosuppressive drugs, cancer or cleft palate deformity) Certificate of Coverage Reference Guide D-1

36 Physician Fees for Surgical and Medical Services Benefit Clarification: Changed from Professional to Physician Fees. Radiology, anesthesiology, pathology and laboratory expenses will be paid according to network status of the facility. Deductible and coinsurance apply. Choice: Not Applicable Choice Plus: Not Applicable PPO: Not Applicable Notification Requirement Not Applicable Non-notification Penalty: Not Applicable D Certificate of Coverage Reference Guide

37 Pregnancy Maternity Services Benefit Clarification: One office visit copayment is required at the first visit for pregnancy; applies to the Physician services for prenatal care, delivery and post-natal care. If the plan design does not have an office visit copayment, Network services will pay according to Network benefit coinsurance. Non-Network services will pay according to Non-Network benefit coinsurance. Includes language required by Federal Law that clarifies no notification needed for 48/96-hour inpatient admission. Member notification is requested but not required for pregnancy. Notification allows covered person to be enrolled in prenatal program. Choice: Not Applicable Choice Plus: Non-Network services only PPO: Network and Non-Network services Notification Requirement: Notification is required within 24 hours if inpatient stay exceeding Federal time frames (48 hours for vaginal delivery/96 hours for c-section delivery) Notification is required within 5 business days or as soon as reasonably possible for an inpatient stay related to complications of pregnancy Non-notification Penalty: Coverage is reduced to 50% of eligible expenses 2007 Certificate of Coverage Reference Guide D-3

38 Skilled Nursing Facility Inpatient Rehabilitation Facility Services Benefit Clarification: Benefits are only available if progressing in goal-directed rehabilitation services or if discharge rehabilitation goals have not been met. Limited to 60 days per calendar year for combined Network and Non-Network. Deductible and coinsurance apply. Rationale: Skilled Nursing Facility benefits are clarified to indicate that services for patients who are not making progress in rehabilitation goals are not covered. Choice: Not Applicable Choice Plus: Non-Network services only PPO: Network and Non-Network services Notification Requirement: Within 5 business days for scheduled admissions or as soon as reasonably possible Covered person is responsible for additional Non-Network notification 24 hours prior to scheduled admissions Non-notification Penalty: Coverage is reduced to 50% of eligible expenses D Certificate of Coverage Reference Guide

39 E. Pre-service Notification Pre-service Notification Requirements: Choice/ Choice Plus/ Options PPO: Notification requirements may apply to either Network or Non-Network services or both based on specific benefit categories Notification Requirement: Pre-service Notification is required within 5 business days for scheduled admissions, or 1 business day for nonscheduled admissions or as soon as reasonably possible Covered person is required to make additional notification 24 hours before Non-Network scheduled admissions. However, covered person will not be penalized if the second notification requirement is not met Non-notification Penalty: Coverage may be reduced to 50% of eligible expenses or no benefits will be paid RATIONALE Notification is required for before receiving certain covered health services. Generally Network providers are responsible for notification. Non-Network providers are not responsible for this notification and patients should contact UnitedHealthcare before receiving services Certificate of Coverage Reference Guide E-1

40 2007 COC Pre-Service Notification Summary - Member Responsibility for Notification Service Category Specific services in the category requiring notification Nwk Choice Choice Plus Non- Nwk Nwk Non- Nwk PPO & Non-diff PPO Nwk Non- Nwk Admission Notification 24 hr before IP Admit Pre-Service Notification timing 5 day prior ASAP No benefit paid Non-notification Penalty Ambulance Non-emergent air/ground Y N/A Y Y Y Y X X Clinical Trials All Y N/A Y Y Y Y X X Congenital Heart Disease CHD surgeries N N/A N Y Y Y X X Dental Services All Y N/A Y Y Y Y X X Diabetes Treatment insulin pump > $1,000 N N/A N Y Y Y X X DME All > $1,000 N N/A N Y Y Y X X Emergency Services N/A N/A N/A N/A N/A N/A Home Health Care All N N/A N Y Y Y X X Hospice IP admit only N N/A N Y Y Y X X X Hospital - In-Patient All scheduled admits admits N N/A N Y Y X X X X Lab, Xray & Diagnositcs N N/A N N N N Lab/Xray - CT, PET, MRI N N/A N N N N MH/SA Out-Patient All Y N/A Y Y Y Y X X MH/SA In-Patient All Y N/A Y Y Y Y X X Ostomy supplies N/A N/A N/A N/A N/A N/A Pharmaceutical Products N N/A N N N N Physician Fees N/A N/A N/A N/A N/A N/A Physician Office Services N/A N/A N/A N/A N/A N/A Pregnancy - Maternity If exceeds mandate LOS N N/A N Y Y Y X X Preventive Care Services N/A N/A N/A N/A N/A N/A Prosthetic Devices N N/A N N N N Reconstructive Proc. All N N/A N Y Y Y X X X Rehab Services OP Chiro only N N/A N Y Y Y X X Scopic procedures - OP N/A N/A N/A N/A N/A N/A SNF/Acute Rehab All N N/A N Y Y Y X X X Surgery - Outpatient N N/A N N N N TMJ - Al All N N/A N N Y N Y N Y X X X Therapeutics - OP Dialysis only N N/A N Y Y Y X X X Transplantation Services All Y N/A Y Y Y Y X X X Urgent Care N/A N/A N/A N/A N/A N/A Vision Exam N/A N/A N/A N/A N/A N/A Reduction to 50% of Eligible Expenses E Certificate of Coverage Reference Guide

41 F. Exclusions Alternative Treatments Benefits Excluded: Music therapy, dance therapy, art therapy, aroma therapy and horseback therapy Certificate of Coverage Reference Guide F-1

42 Physical Appearance Breast Reduction Benefits Excluded: Breast reduction surgery, other than to comply with Women s Cancer Rights Act of F Certificate of Coverage Reference Guide

43 Procedures and Treatment Standalone Smoking Cessation Benefits Excluded: Standalone Smoking Cessation Programs 2007 Certificate of Coverage Reference Guide F-3

44 G. Pharmacy UnitedHealth Pharmaceutical Solutions SM (UHPS) is pleased to introduce several new pharmacy management capabilities and programs that will allow us to enhance the affordability of medications for our customers and members. The following programs will help ensure more appropriate use of medications and help continue our history of market-leading pharmacy trends. What s New in 2007? The 2007 Pharmacy Rider includes several capabilities that will support our affordability and quality goals. The following represent the major changes in the 2007 Pharmacy Rider that are expected to receive widespread state approval throughout the year. Each of these capabilities will be implemented at the time of the Pharmacy Rider implementation in each state and upon renewal. Optimal Benefit Design changes Limited Medications through Mail Order ProgressionRx (also called step therapy) Coordination of Benefits (COB) enhancement Therapeutically equivalent medication exclusions G Certificate of Coverage Reference Guide

45 Optimal Benefit Description: Our 2007 national portfolio plans support new criteria for our Optimal Benefit designs. Tier 2 copays have increased by $5 and Tier 3 copays by $5 to $10. The new Optimal Benefit designs are currently available to renewals and new business. The following represents the new Optimal Benefit copay structure: Tier 1: $7-$10 copay Tier 2: $25-$35 copay (with at least a $15 spread from Tier 1) Tier 3: $50-$70 copay (with at least a $20 spread from Tier 2) Benefits: Optimal Benefit Designs are a key component of our overall long term cost and premium abatement strategy. Benefits include: Improved financial performance Aligned member cost share with the evidence supported value of the choices members make with their physicians Preserved member access to important drug therapies and affordable choices Improved prices with pharmaceutical manufacturers Lower overall pharmacy trend 2007 Certificate of Coverage Reference Guide G-2

46 Limited Products through Mail Order Description: This capability will require that certain medications be filled via a retail pharmacy for coverage under the pharmacy benefit. Medications included are typically for acute conditions. A 90-day supply of these medications will not be allowed through the mail order pharmacy. The 90-day supply typically allowed through mail order is not always appropriate and can incur additional cost through wasted medication. Benefits: Limiting products through mail order will save on pharmaceutical spend by decreasing wasted medication (e.g., only 30 days supply is used of a 90-day supply of medication). There are some medications that can be better managed through the retail environment than the mail environment by requiring no more than a 30-day supply be covered per script. Mail order is a cost-effective and convenient option for certain medications for chronic conditions (e.g., maintenance medications). In these instances, members will be able to use the mail order pharmacy for prescription fulfillment. G Certificate of Coverage Reference Guide

47 ProgressionRx (also called step therapy) Description: ProgressionRx, also known as step therapy, is a real-time point-of-service (POS) program that requires the failure of one or more medications before another medication is covered. So one medication or step must be tried before another. When presented with a prescription for one of these medications at the pharmacy, the claim adjudication system will check the member s claim history to determine if one of the alternatives has been tried. If not, the system will deny coverage for the prescription. The member may choose to pay the full price of the medication, or contact his or her doctor to change the prescription or contact customer service for a coverage review of the medication. The 2007 Pharmacy Rider initially supports step therapy for the following medication, but others may be added as appropriate. Cesamet: Indicated for nausea and vomiting in patients who have failed to respond adequately to conventional treatments. Manufacturer: Valeant Benefits: ProgressionRx will be used only in limited and strategic situations, so it will not conflict with our goal of ensuring members have access to the medications they need. Step therapy encourages more appropriate medication use Certificate of Coverage Reference Guide G-4

48 Coordination of Benefits (COB) Description: The new COB capability allows us to process prescription claims for members with UnitedHealthcare as secondary coverage at the point-of-service. Members must first submit their primary insurance cards for processing. The member may then submit his or her UnitedHealthcare ID card at the pharmacy, and the claim will be adjudicated real-time at the secondary coverage amount. Benefits: Customers can offer more convenient COB processing to their employees. Real-time adjudication of secondary coverage is convenient and much less disruptive to members than paying out of pocket at the POS and submitting a paper claim for reimbursement of their secondary coverage. This enhanced COB process makes accessing benefits simpler and easier. G Certificate of Coverage Reference Guide

49 Therapeutic Equivalents Description: This language will allow a medication exclusion if there is a therapeutically equivalent prescription medication that is covered under the benefit. The therapeutic equivalent may be a brand or generic medication and can include modified versions of existing drugs. The Pharmacy Rider supports an exclusion if there is a therapeutically equivalent over-the-counter (OTC) product as well as expands the exclusion to therapeutically equivalent prescription drugs. Benefits: Medication exclusions are not implemented lightly. There is significant analysis and professional market input that occurs before an exclusion decision is made. When decisions are made based on sound evidence and real-world experience, exclusions are an effective way to significantly manage cost in a category while providing access to medication options for members Certificate of Coverage Reference Guide G-6

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52 Terms and Conditions: This summary of benefits information is intended only to highlight benefits and should not be relied upon to fully determine coverage. Brokers, customers and members should refer to the Certificate of Coverage for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. If a description conflicts in any way with the Certificate of Coverage, the Certificate of Coverage prevails. M /08 Broker 2008 United HealthCare Services, Inc.