health savings plan for cvs health - myuhc.com · health savings plan for cvs health effective:...

Health Savings Plan for CVS Health

Effective: June 1, 2016 Group Number: 701388

Passport Connect Provider Network:

If you reside in New Hampshire, Massachusetts or Maine, the provider network is established by HPHC Insurance Company. If you reside outside of New Hampshire, Massachusetts or Maine, the provider network is the network established by UnitedHealthcare Services, Inc.

HEALTH SAVINGS PLAN

I TABLE OF CONTENTS

TABLE OF CONTENTS

SECTION 1 - INTRODUCTION ......................................................................................................... 1

SECTION 2 – ELIGIBILITY AND ENROLLMENT ............................................................................ 4

Eligibility ....................................................................................................................................... 4

How to Enroll and When Your Coverage Begins .................................................................. 9

Level of Coverage ...................................................................................................................... 12

Paying For Coverage ................................................................................................................. 12

Changing Your Coverage .......................................................................................................... 12

Coverage for Members Who are Hospitalized on Their Effective Date ........................... 14

SECTION 3 – HOW THE HSP WORKS ......................................................................................... 15

Overview of the Health Savings Plan (HSP) ......................................................................... 15

Overview of the Health Savings Account (HSA) ................................................................. 16

Health Savings Plan Features ................................................................................................... 18

A Qualifying Event May Affect Your Plan Deductible and Out-of-Pocket Maximum .. 21

Network and Non-Network Benefits ..................................................................................... 21

Health Care Reform Notice – Choice of Provider ............................................................... 23

Coverage While Traveling Outside the United States .......................................................... 23

SECTION 4 – PERSONAL HEALTH SUPPORT ............................................................................ 24

Prior Authorization .................................................................................................................... 25

Covered Health Services which Require Prior Authorization ............................................. 25

Special Note Regarding Medicare ............................................................................................ 27

SECTION 5 – MEDICAL PLAN HIGHLIGHTS ............................................................................... 28

SECTION 6 - ADDITIONAL COVERAGE DETAILS ...................................................................... 36

Ambulance Services - Emergency Only ................................................................................. 36

Ambulance Services - Non-Emergency .................................................................................. 36

Blood Transfusions .................................................................................................................... 37

Cancer Resource Services (CRS) ............................................................................................. 37

Clinical Trials - Routine Patient Care Costs ........................................................................... 38

Congenital Heart Disease (CHD) ............................................................................................ 39

Dental Services ........................................................................................................................... 40

HEALTH SAVINGS PLAN

II TABLE OF CONTENTS

Diabetes Services ....................................................................................................................... 42

Dialysis ......................................................................................................................................... 42

Durable Medical Equipment (DME) ...................................................................................... 42

Emergency Health Services ...................................................................................................... 44

Enteral Nutrition ........................................................................................................................ 44

Family Planning .......................................................................................................................... 45

Gender Identity Disorder Treatment ...................................................................................... 45

Hearing Exams ........................................................................................................................... 46

Home Health Care ..................................................................................................................... 46

Hospice Care .............................................................................................................................. 47

Hospital - Inpatient Stay ........................................................................................................... 47

Infertility Services and Reproductive Resources Services (RRS Program) ........................ 48

Injections in a Physician's Office ............................................................................................. 50

Lab, X-Ray and Diagnostics - Outpatient .............................................................................. 50

Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient................................................................................................................................. 50

Mental Health Services .............................................................................................................. 50

Neurobiological Disorders - Autism Spectrum Disorder Services ..................................... 52

Nutritional Counseling .............................................................................................................. 53

Obesity Surgery .......................................................................................................................... 54

Ostomy Supplies ........................................................................................................................ 54

Physician Fees for Surgical and Medical Services ................................................................. 55

Physician's Office Services ....................................................................................................... 55

Pregnancy - Maternity Services ................................................................................................ 55

Preventive Care .......................................................................................................................... 56

Prosthetic Devices ..................................................................................................................... 62

Reconstructive Procedures ....................................................................................................... 63

Rehabilitation Services - Outpatient Therapy ........................................................................ 64

Scopic Procedures - Outpatient Diagnostic and Therapeutic ............................................. 65

Skilled Nursing Facility/Inpatient Rehabilitation Facility Services .................................... 65

Spinal Treatment and Chiropractic Services .......................................................................... 66

Substance-Related and Addictive Disorder Services ............................................................ 66

Surgery Outpatient ..................................................................................................................... 68

HEALTH SAVINGS PLAN

III TABLE OF CONTENTS

Temporomandibular Joint Dysfunction (TMJ) ..................................................................... 68

Therapeutic Treatments - Outpatient ..................................................................................... 68

Transplantation Services ........................................................................................................... 69

Travel and Lodging .................................................................................................................... 70

Urgent Care Center Services .................................................................................................... 71

Virtual Visits ............................................................................................................................... 71

SECTION 7 - RESOURCES TO HELP YOU STAY HEALTHY ...................................................... 72

Consumer Solutions and Self-Service Tools .......................................................................... 72

Disease and Condition Management Services ....................................................................... 75

SECTION 8 - EXCLUSIONS: WHAT THE MEDICAL PLAN WILL NOT COVER .......................... 77

Alternative Treatments .............................................................................................................. 77

Comfort and Convenience ....................................................................................................... 77

Dental .......................................................................................................................................... 78

Experimental, Investigational or Unproven Services ........................................................... 79

Foot Care .................................................................................................................................... 79

Gender Identity Disorder Treatment ...................................................................................... 79

Medical Supplies and Appliances ............................................................................................. 80

Mental Health, Neurobiological Disorders - Autism Spectrum Disorder and Substance-Related and Addictive Disorders Services .............................................................................. 80

Nutrition and Health Education .............................................................................................. 81

Physical Appearance .................................................................................................................. 81

Prescription Drugs (Including Specialty Medications) ......................................................... 82

Providers ..................................................................................................................................... 84

Reproduction .............................................................................................................................. 84

Services Provided under Another Plan ................................................................................... 85

Transplants .................................................................................................................................. 85

Travel ........................................................................................................................................... 86

Vision and Hearing .................................................................................................................... 86

All Other Exclusions ................................................................................................................. 86

SECTION 9 – CLAIMS AND APPEALS PROCEDURES ............................................................... 89

Network Benefits ....................................................................................................................... 89

Non-Network Benefits ............................................................................................................. 89

HEALTH SAVINGS PLAN

IV TABLE OF CONTENTS

Claims and Appeals ................................................................................................................... 89

Keeping Records of Expenses ................................................................................................. 90

Filing and Processing Claims ................................................................................................... 90

Time Frames for Claim Processing ......................................................................................... 91

Extensions of Time Frames ..................................................................................................... 92

Notice of Claim Denial ............................................................................................................. 92

Appealing a Medical Claim Decision ...................................................................................... 93

External Review ......................................................................................................................... 96

Claims That Qualify for External Review .............................................................................. 97

Deadline for Requesting an External Review ........................................................................ 97

Preliminary Review .................................................................................................................... 97

Referral to IRO .......................................................................................................................... 98

Expedited External Review ...................................................................................................... 99

Legal Action .............................................................................................................................. 100

Complaints ................................................................................................................................ 100

Recovery of Overpayment ...................................................................................................... 100

SECTION 10 - COORDINATION OF BENEFITS (COB) .............................................................. 101

Determining Which Plan Is Primary ..................................................................................... 101

When This Plan Is Secondary ................................................................................................ 102

When a Covered Person Qualifies for Medicare ................................................................. 103

Right to Receive and Release Needed Information ............................................................ 104

Overpayment and Underpayment of Benefits ..................................................................... 104

SECTION 11 - RIGHTS OF SUBROGATION, REIMBURSEMENT AND RECOVERY ................ 106

Subrogation ............................................................................................................................... 106

Reimbursement ........................................................................................................................ 107

When You Accept Plan Benefits ........................................................................................... 107

Applicability to All Settlements and Judgments .................................................................. 108

Interpretation ............................................................................................................................ 109

Right of Recovery .................................................................................................................... 109

SECTION 12 - WHEN COVERAGE ENDS ................................................................................... 110

Rescissions of Coverage .......................................................................................................... 111

Erroneous Claims and Administrative Errors ..................................................................... 111

HEALTH SAVINGS PLAN

V TABLE OF CONTENTS

Loss of Benefits ........................................................................................................................ 112

Continuation Coverage under the Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA) ................................................................ 112

Continuing Coverage during Family and Medical Leave Act (FMLA) Leave ................ 113

Continuing Coverage during Leaves of Absences (Other than FMLA or USERRA) .. 115

Continuing Coverage under COBRA ................................................................................... 115

SECTION 13 - OTHER IMPORTANT INFORMATION ................................................................. 121

Qualified Medical Child Support Orders (QMCSOs) ........................................................ 121

Your Relationship with UnitedHealthcare and CVS .......................................................... 122

Relationship with Providers ................................................................................................... 122

Your Relationship with Providers ......................................................................................... 123

Incentives to Providers ........................................................................................................... 123

Incentives to You ..................................................................................................................... 124

Workers' Compensation Not Affected ................................................................................. 124

Interpretation of Benefits ....................................................................................................... 124

Your Privacy Rights under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) .......................................................................................................................... 124

Your ERISA Rights ................................................................................................................. 128

SECTION 14 - IMPORTANT ADMINISTRATIVE INFORMATION ............................................... 131

Plan Information ...................................................................................................................... 131

Plan is Not an Employment Contract .................................................................................. 134

Future of the Plan .................................................................................................................... 134

SECTION 15 - GLOSSARY .......................................................................................................... 135

HEALTH SAVINGS PLAN

1 SECTION 1 - INTRODUCTION

SECTION 1 - INTRODUCTION

Quick Reference Box ■ Member services, claim inquiries, Personal Health Support and Mental Health/

Substance-Related and Addictive Disorder Services Administrator: 1-800-809-9577

■ Claims submittal address: UnitedHealthcare - Claims, P.O. Box 740800, Atlanta, GA 30374-0800

■ Online assistance: www.myuhc.com (residents in NH use www.myharvardpilgrim.org)

■ Report address and family status changes: myHR – at 1-888-MY-HR-CVS (1-888-694-7287)

■ Health and medication information, tools to understand health and links to carrier resources: myhr.cvs.com

This Health Savings Plan (the “HSP”) is an important employee benefit designed to help keep good health care affordable for you and your family. It provides benefits for preventive care and access to special programs that focus on helping you stay healthy, plus the coverage you need when faced with an illness or injury.

The HSP (also the “plan”) is a component plan under the CVS Health Welfare Benefit Plan (the “Plan”) which is maintained by the Plan Sponsor, CVS Pharmacy, Inc. and its related entities and divisions that participate in the Plan (collectively, “CVS”).

This booklet is designed to provide a clear and understandable Summary of the HSP and serves as the Summary Plan Description (SPD) required for plans subject to ERISA such as the HSP. The SPD can help you understand the main features of the plan, such as:

■ who is eligible;

■ services that are covered, called Covered Health Services;

■ services that are not covered, called Exclusions;

■ how Benefits are paid;

■ how to file a claim;

■ what happens when you are no longer eligible for coverage; and

■ your rights and responsibilities under the plan.

This SPD is designed to meet your information needs and the disclosure requirements of the Employee Retirement Income Security Act of 1974 (ERISA). It supersedes any previous printed or electronic SPD for the Plan. Because the HSP is a component plan under the CVS Health Welfare Benefit Plan (the “Plan”), the benefits described in this SPD are also governed by the terms of the separate governing plan documents, including the CVS Health Welfare Benefit Plan document. If there is a conflict between this SPD and the legal plan documents controlling the operation of the Plan, the legal document will govern.

HEALTH SAVINGS PLAN


Although CVS currently intends to continue the Benefits provided by the plan, CVS reserves the right, at any time and for any reason or no reason at all, to amend, interpret, modify, withdraw or add benefits or terminate the plan or this SPD, in whole, or in part and in its sole discretion, without prior notice to or approval by plan participants and their beneficiaries. Any change or amendment to or termination of the plan, its Benefits, or its terms and conditions, in whole or in part, shall be made solely in a written amendment (in the case of a change or amendment) or in a written resolution (in case of termination), whether prospective or retroactive to the plan. The amendment is effective only when approved by the body or person to whom such authority is formally granted by the terms of the plan. No person or entity has any authority to make oral changes or amendments to the plan. This SPD is not to be construed as a contract of or for employment.

The HSP described in this SPD is administered by UnitedHealthcare, a private healthcare claims administrator. UnitedHealthcare's goal is to give you the tools you need to make wise healthcare decisions. UnitedHealthcare also helps your employer to administer claims. Although UnitedHealthcare will assist you in many ways, it does not guarantee any Benefits. CVS is solely responsible for paying Benefits described in this SPD.

Please read this SPD thoroughly and refer to it when you to understand how your medical benefits in the HSP work. If you have questions or need help, call the number on the back of your ID card or myHR at 1-888-MY-HR-CVS (1-888-694-7287).

How to Use This SPD ■ Read the entire SPD, and share it with your family. Then keep it in a safe place for

future reference.

■ Many of the sections of this SPD are related to other sections. You may not have all the information you need by reading just one section.

■ You can request copies of your SPD and any future amendments by calling the number on the back of your ID card.

■ Capitalized words in the SPD have special meanings and are defined in Section 15, Glossary.

■ If eligible for coverage, the words "you" and "your" refer to Covered Persons as defined in Section 15, Glossary.

■ CVS is also referred to as Company.

■ If there is a conflict between this SPD and any benefit summaries (other than Summaries of Material Modifications) provided to you, this SPD will control.

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Disclaimer CVS Human Resources (HR) and UnitedHealthcare employees often respond to outside inquiries regarding coverage as part of their job responsibilities. These employees do not have the authority to extend or modify the benefits provided under the HSP.

In the event of a discrepancy between information given by either a CVS HR or UnitedHealthcare employee and the written terms of the plan, the terms of the plan will control.

Any changes or modifications to benefits under the plan must be provided in writing and made according to the plan’s amendment procedures.

Administrative errors will not invalidate benefits otherwise in force or give rise to rights or benefits not otherwise provided by the plan.

HEALTH SAVINGS PLAN

4 SECTION 2 - ELIGIBILITY AND ENROLLMENT

SECTION 2 – ELIGIBILITY AND ENROLLMENT

What This Section Includes: ■ Who's eligible for coverage under the HSP;

■ The factors that impact your cost for coverage;

■ Instructions and timeframes for enrolling yourself and your eligible Dependents;

■ When coverage begins; and

■ When you can make coverage changes under the HSP.

Eligibility

Your Eligibility

You are eligible for medical coverage under the HSP if you are considered an eligible employee, as described below, and you are working in the United States.

The date on which you are first eligible for coverage is your “Eligibility Date”.

In compliance with the Patient Protection and Affordable Care Act (PPACA), CVS measures hours of service for benefits eligibility for employees who are not hired into exempt positions.

Generally, an “hour of service” is an hour actually worked, an hour for which you are paid (such as vacation, PTO or time on leave), or an hour during which you are on an approved unpaid leave of absence. CVS will evaluate your hours to determine whether you qualify for medical coverage under the Measurement Period rules, described below.

Special rules apply if you have a break in service, take a leave of absence, or change your job classification. For questions regarding eligibility, contact myHR at 1-888-MY-HR-CVS (1-888-694-7287).

New Hires

If you are a new hire, you are considered an eligible employee as of your date of hire if you are hired into an exempt position or other position in which you are expected to work at least 30 hours per week. Your Eligibility Date is the 91st day of continuous employment with CVS. If you are in a non-exempt position, your continued eligibility will depend on whether you meet the requirements for current employees as described below.

If you are a new hire who is not hired into a position in which you are expected to work at least 30 hours per week, you are not considered an eligible employee. However, you may become an eligible employee if you average 30 or more “hours of service” (described above under “Your Eligibility”) per week during your initial Measurement Period, as defined below.

HEALTH SAVINGS PLAN


If you are a new hire who is not hired into an exempt position, your hours of service will be measured for future benefits eligibility, as follows:

■ Beginning with your date of hire, your average hours worked in the first 11 months of your employment, which is your initial Measurement Period, will be measured.

■ An administrative period of less than 90 days will follow the initial Measurement Period, during which you will be notified if you have become eligible for coverage during your initial Stability Period, as defined below. If you have become eligible, you will also be notified of your eligibility date and how to elect coverage, if applicable.

■ Your Eligibility Date will generally be the 1st of the second calendar month following the end of the initial Measurement Period. In some cases, depending on your date of hire, your Eligibility Date could be the 1st of the first calendar month following the end of your initial Measurement Period.

■ If you average 30 or more hours of service during your initial Measurement Period, you will be eligible for and offered medical benefits under the plan beginning with your Eligibility Date for a 12 month period, which is called your initial Stability Period.

■ After the end of your initial Stability Period, you will remain covered through the end of the then-current Plan Year, only if you averaged 30 hours or more during the most recent completed annual ongoing Measurement Period (March 3 of preceding year through March 2 of current year, as discussed further below under the “Current Employees” section)

■ You will be continuously measured as a current employee going forward, as outlined below, for medical benefits eligibility.

Current Employees

If you are in an exempt position, you are eligible to elect medical coverage under the HSP during the Annual Enrollment Period and if you are enrolled in medical coverage under the plan and move to a non-exempt position in which you are working less than 30 hours per week you will remain covered under the plan for the remainder of the Plan Year.

If you are a current employee who is not in an exempt position, you are considered an eligible employee for a Stability Period under the plan (described below) if, during the related Measurement Period under the plan (described below) immediately preceding the Stability Period, you are an employee of CVS and you average 30 or more hours of service per week.

HEALTH SAVINGS PLAN


Stability Period and Measurement Period A Stability Period is a 12 month period beginning on June 1 and ending on May 31 and coincides with the Plan Year. In determining whether you are an eligible employee for a Stability Period, the Plan Administrator will review your average hours of service during the Measurement Period that immediately precedes the Stability Period. A Measurement Period is a 12 month period beginning on March 3 and ending on March 2 of the current year.

■ If you average 30 or more hours of service per week during a Measurement Period, you will be considered an eligible employee for the upcoming Stability Period and Plan Year (June 1 through May 31).

■ You will be notified of your Eligibility Date and how to elect coverage for the upcoming Plan Year.

■ Continued eligibility for medical benefits is reviewed at the end of each Measurement Period for all current employees not in exempt positions.

Rehires

If you terminate employment with the Company and are rehired by the Company, you will be treated as a new hire only if the period between the termination and rehire exceeds 13 consecutive weeks.

Additional Eligibility Requirements

In order to be considered an eligible employee, you must also satisfy the following additional eligibility requirements (“Additional Eligibility Requirements”):

■ You are not covered by a collective bargaining agreement where benefits were the subject of good faith bargaining (unless that agreement provides for participation in the plan).

■ You are not classified, by CVS in its sole discretion under its customary worker classification procedures, as a leased employee, independent contractor, consultant or other designation that would exclude eligibility (whether or not you actually are an employee and regardless of whether you are later reclassified as an employee by a governmental agency for the period at issue), unless your specific contract or agreement with CVS provides for coverage under the plan.

■ You have been determined by the Plan Administrator to live in the Service Area covered under the respective plan.

Dependent Eligibility

You may enroll your eligible dependents (described below) when you are first eligible for medical coverage and during the plan’s Annual Enrollment period. Generally, you may also enroll newly eligible dependents within 30 days of their becoming eligible by marriage and

HEALTH SAVINGS PLAN


within 60 days of their becoming eligible by birth, adoption, or placement for adoption. You may only drop coverage of an eligible dependent upon a Change in Status event (described below) or during the plan’s Annual Enrollment period, unless your dependent’s coverage is paid for on an after-tax basis (in which case you can disenroll that dependent at any time).

No person can be covered as both an employee and a dependent. In addition, no dependent may be covered without the employee having coverage. No person can be covered as a dependent of more than one employee under the plan.

You should be aware that not all coverage for eligible dependents under the plan can be paid for on a pre-tax basis. As discussed under the “Paying for Coverage” section below, due to current tax laws coverage for dependents can be paid for on a pre-tax basis only if the dependent:

■ is your legal spouse, your biological child, adopted child, step-child, child for whom you are the legal guardian, or a child who is the subject of a “qualified medical child support order” (“QMCSO”) or

■ meets the IRS’ definition of a tax dependent under Section 152 of the Internal Revenue Code.

Shortly after you enroll a dependent, CVS’ audit partner, Dependent Verification Services, will send you a letter requesting proof that your dependent is eligible under the terms of the plan. Required documentation may include a government-issued marriage certificate, government-issued birth certificate, and a Federal tax return.

Note that a child who is not your biological child, legally adopted child, or child for whom you are the legal guardian is not your eligible dependent if you divorce or legally separate from, or otherwise terminate the relationship with your legal spouse.

Note: If a Covered Person is determined to be ineligible or unverified, he or she will be dropped from coverage under the plan, and you will be required to pay to the plan all claims incurred on behalf of ineligible or unverified person(s). If this is the case, you may not be eligible for future coverage under the plan until you pay all amounts owed. If the termination of coverage for such person results in a coverage level change, such as from family to individual coverage, you will not be refunded any premiums deducted from your pay at the higher coverage level. Your coverage level will be adjusted only for the pay periods that occur after the removal of any ineligible or unverified dependent(s).

HEALTH SAVINGS PLAN


Eligible Spouse

■ Your legal spouse* of the same or opposite sex is eligible for medical benefits under the plan. To confirm eligibility for coverage under the plan, CVS requires a copy of your marriage certificate and proof that you remain married.

*If you are legally separated from your spouse, your spouse is not an eligible dependent.

Eligible Children

The following is a list of dependent children who are eligible for medical benefits under the plan.

■ A child up to age 26*, where the child is one of the following:

- Your biological child, legally adopted child (including a child placed with you for adoption), step-child** from a legal spouse, or child for whom you are the legal guardian (as determined by an authorized placement agency, or by judgment, decree, or any order of a court).

*Coverage may continue for the entire calendar month during which he or she attains age 26.

**A child who is your step-child will no longer be an eligible dependent in the event of a divorce or legal separation.

- Your legal spouse’s legally adopted child, or a child for whom your legal spouse is the legal guardian (as determined by an authorized placement agency, or by judgment decree, or any order of a court).

■ Your, your legal spouse’s unmarried grandchild, provided he or she:

- is also your tax dependent,

- resides with you for more than one-half of the year (or, if less than one-half of the year has resided with you since birth or adoption), and

- receives over 50% of his or her support and maintenance from you, your spouse or eligible domestic partner.

Shortly after you enroll a dependent, you will be required to attest to the Plan Administrator (and provide supporting documentation) that a child meets the above requirements. In addition, you may be asked to re-certify annually that a grandchild continues to meet the plan’s requirements.

■ A child who is 26 or older and has a physical or mental disability that is expected to last for a continuous period of not less than 12 months (as determined by the Insurance Company or Claims Administrator, as applicable), provided the child:

- is incapable of engaging in substantial gainful activity;

- receives over 50% of his or her support and maintenance from you, your legal spouse; and

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- has the same residence as you for more than one-half of the year (or if less than one-half of the year, has resided with you since birth or adoption).

You must provide proof of the ongoing disability as often as requested by the plan. The child must be disabled prior to age 26 or become disabled while covered as a dependent under the plan for purposes of medical benefits.

■ A child who is the subject of a “qualified medical child support order” (“QMCSO”) as determined by a judgment, decree, or any order of a court. Note that the Plan Administrator will not recognize an order that requires a child of your legal spouse (other than your step-child) to be covered under the plan if your spouse does not live with you.

How to Enroll and When Your Coverage Begins

General Enrollment You will be notified of your Eligibility Date and how to elect coverage. You are then required to take action before your Eligibility Date. You can enroll from home or work anytime (24/7) by logging onto: myhr.cvs.com. Once at the myhr.cvs.com site, you will need to follow the prompts on screen to make your coverage elections. When you enroll at myhr.cvs.com, your Eligibility Date will be reflected. Also, additional instructions are supplied with your enrollment materials. Customer Service Representatives are available to answer your enrollment questions. Call myHR at 1-888-MY-HR-CVS (1-888-694-7287), 24 hours a day, 7 days a week.

You must enroll prior to your Eligibility Date, otherwise you will have waived coverage. If you waive coverage, you will need to wait to enroll, assuming you are eligible, until the next Annual Enrollment period that begins in April or until your next enrollment opportunity. You may be able to enroll mid-year if you experience a Change in Status or a Special Enrollment event (described below). Your enrolled dependents’ coverage takes effect on the same date your coverage takes effect.

Rehires. If you are a rehired employee who returns to an employment position in which you are expected to work at least 30 hours per week within 13 weeks of your date of termination, you remain eligible based on your prior period of employment, but you still must make new benefit elections. The benefit elections you had in place on your last day of employment will not automatically resume on the date you are rehired, and you will have to re-enroll in benefits.

By enrolling in the plan, you authorize CVS to deduct coverage contributions from your pay. In the event you owe premiums to the plan, you are also authorizing CVS to deduct the outstanding benefit contribution balance through payroll deductions in an amount not to exceed double the required contribution of the benefit option and level you selected, until the balance is repaid in full. Any questions about enrolling should be directed to myHR at 1-888-MY-HR-CVS (1-888-694-7287).

Annual Enrollment The Annual Enrollment period is the annual period of time during which you are given the opportunity, assuming you are eligible, to enroll in the plan, drop coverage, or change your

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coverage level (for example, from employee to employee plus one or more children). The Annual Enrollment period commences in April, and elections made during this period are effective June 1. You may need to reenroll in the plan during each Annual Enrollment period to continue your previous year’s coverage. Look for information from CVS regarding Annual Enrollment to determine whether reenrollment action is required to continue coverage into the next Plan Year.

Special Enrollment Ordinarily, if you do not enroll for medical coverage when you are first eligible, you must wait until the next Annual Enrollment period. However, in certain cases if you are eligible during a Plan Year or portion of the Plan Year, you and/or your dependents may be eligible for “Special Enrollment” outside of the Annual Enrollment period. If this is the case, you may make election changes concerning your medical benefits under the plan. You may also change benefit options when a Special Enrollment event is the result of marriage, birth, or adoption.

If you or your dependent experience a Special Enrollment event described below under Special Enrollment Rules, you must take action within the time period described below to make your election change. You can do this by logging onto myhr.cvs.com, or calling myHR at 1-888-MY-HR-CVS (1-888-694-7287) during normal business hours – to advise CVS of the Special Enrollment event and make your election change. Once at myhr.cvs.com, look for the “Life Events” menu, which will provide you with directions on how to make your election change online. If you do not see the life event that pertains to you at myhr.cvs.com, be sure to call myHR within the required time period to make your election change. Note that for Special Enrollment events relating to Medicaid or CHIP eligibility, you must call myHR within the required time frame to make your election change (online election changes due to these events are not available).

Note: Coverage is retroactive to the date of the event or loss of coverage, provided you complete the enrollment transaction by the required deadline. By completing the enrollment transaction, you authorize CVS to deduct contributions required for retroactive coverage from your pay.

Special Enrollment Rules If you are in a position in which you are expected to work at least 30 hours per week, you have special enrollment rights (described below). If you are not in a position in which you are expected to work at least 30 hours per week, but were considered eligible for medical coverage due to your hours of service during a Measurement Period, you will have special enrollment rights described below during the Stability Period that applies to you.

Loss of Other Coverage If you decline enrollment in medical benefits under the HSP for yourself and your dependents due to your other health coverage, you may be able to enroll yourself and your dependents for these benefits under the plan within 30 days after the other coverage ends. Go to myHR at myhr.cvs.com.

For this Special Enrollment event to apply, you must have stated that you were declining coverage under the plan for you and/or your dependents due to other health coverage, and you or your dependent’s other coverage must be lost because it was one of the following:

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■ COBRA coverage that was exhausted,

■ other coverage for which you or your dependent are no longer eligible (for example, by reason of legal separation, divorce, death, termination of employment, reduction in the number of hours of employment, or incurring a claim that would meet or exceed a lifetime limit on all benefits under the other coverage), or

■ the coverage was provided by another employer that ceased to pay for it.

If you fail to provide the written statement required above (stating that you were declining coverage due to coverage under another plan), the plan may not provide Special Enrollment to you or any of your dependents.

Note: Neither a loss of coverage due to a failure to pay premiums nor a loss of coverage for cause (such as making a fraudulent claim or an intentional misrepresentation) will trigger Special Enrollment rights.

Addition of New Dependent If you have a new dependent because of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependent for medical/prescription coverage under the plan, provided you enroll your new dependent within 30 days after your date of marriage and within 60 days after a birth, adoption, or placement for adoption. To enroll, go to myHR at myhr.cvs.com Changes to your coverage are effective as of the date of the event.

Medicaid and CHIP If you or a dependent are eligible for coverage under the terms of the plan, but you are not enrolled, you or your dependent may enroll for medical/prescription coverage under the terms of the plan if either one of the following conditions is met:

■ you or your dependent are covered under a Medicaid plan or a State child health plan under the Children's Health Insurance Program ("CHIP"), and coverage under the Medicaid or CHIP plan is terminated because of a loss of eligibility for such coverage. You may then request coverage under the plan no later than 60 days after termination of the Medicaid or CHIP coverage, or

■ you or your dependent become eligible for a premium assistance program (that could be used toward the plan costs) under a Medicaid or state child health plan under CHIP (including any waiver or demonstration project conducted under or in relation to such a plan). You may then request coverage under the plan no later than 60 days after the date you or your dependent are determined to be eligible for the premium assistance.

Call myHR at 1-888-MY-HR-CVS (1-888-694-7287) during normal business hours within 60 days after termination of the Medicaid or CHIP coverage or the date you or your dependents are determined to be eligible for premium assistance, as applicable. The call center representative will make your election changes on the phone at the time of your request.

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Level of Coverage

You may choose from four levels of coverage: coverage for you only, coverage for you plus your legal spouse, coverage for you plus one or more children, or family coverage (you, your legal spouse and children).

Paying For Coverage

Generally, you and CVS share the cost of your Plan coverage (with CVS paying the majority of the cost).

Your contributions for plan coverage are not used to pay plan expenses for vendors or other service providers who are affiliated with CVS (such as CVSCaremark), except as may be permitted by ERISA.

Your contributions will be deducted from your pay on a before-tax basis and are subject to change on June 1 of each year or when you change your benefits. Paying for your coverage on a before-tax basis means you don’t pay Social Security or Federal (and, in most cases, state) income tax on your contributions. Since your taxable earnings are lower, you pay less in taxes. Also, CVS’s contributions towards your medical and prescription coverage are not taxed. This before-tax-treatment is available for coverage for your legal spouse (whether same or opposite sex) and for a dependent child who is your biological child, adopted child (or child placed with you for adoption), step-child, or a child for whom you are the legal guardian. However, before-tax treatment is not available for coverage of other dependents unless the dependent is considered your dependent for federal tax purposes.

If you fail to pay monies owed to the plan, the Plan Administrator may pursue any means of collection, including reporting the debt to a credit agency or prohibiting you from enrolling in the plan in the next Annual Enrollment period.

Changing Your Coverage

You may change your coverage under the plan during the Annual Enrollment period each year or during the year if you have a Change in Status as provided below. Changes to your coverage during the year due to a Change in Status are effective as of the date of the Change in Status.

If you want to change your coverage due to a Change in Status, you must go to myHR at myhr.cvs.com to make the change within 30 days of the date of your Change in Status. However, for birth or adoption, you have up to 60 days to make the change. You will be able to report your Change in Status and change your coverage at the same time. If you do not complete the transaction within the required timeframe, you will have to wait until the next Annual Enrollment period to add coverage under the plan.

A change in coverage must be consistent with your Change in Status. For example, if you become divorced, you may drop coverage for your former spouse, but you cannot change your own coverage options. Changes in Status include:

■ marriage, divorce, legal separation or annulment;

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■ birth or adoption (or placement for adoption) of your child, or the addition of your step-children;

■ death of a dependent;

■ change in employment status including termination or commencement of employment, a commencement of or return from an unpaid leave of absence or change in work schedule (including a change from a position in which you are expected to work less than 30 hours per week to a position in which you are expected to work at least 30 hours per week or vice versa) for you or your dependent that affects eligibility for this plan or another employer plan;

■ change in health insurance eligibility due to a relocation of residence or work place for you;

■ a judgment, decree, or order resulting from your marriage, divorce, legal separation, annulment, or change in child custody requiring you to add or allowing you to drop coverage for your dependent child (this is dependent on state mandates);

■ your or your spouse’s or dependent child’s entitlement, or loss of entitlement, to Medicare or Medicaid benefits;

■ a significant increase in cost of coverage, or a reduction in benefits, under the plan or your spouse’s plan;

■ a change in a dependent’s coverage under another employer plan that is permitted under that plan and applicable IRS regulations; and

■ if your spouse gains coverage for you during his/her plan’s annual enrollment, you may drop coverage or if your coverage under another employer plan is dropped at the other plan’s annual enrollment, you may add coverage, provided the period of coverage for that other plan is different than the period of coverage for this plan. You must show documentation from your spouse’s plan of such activity.

You may drop coverage for you and your applicable dependents if:

■ you experience a change in your employment status from a position in which you were expected to work 30 hours or more per week to a position where you are not expected to work 30 hours or more per week, even if you remain eligible for medical and prescription plan coverage, provided you represent that you and any covered dependents have enrolled or intend to enroll in another plan that provides minimum essential coverage (such as Marketplace coverage or coverage through another employer medical plan) for new coverage that is effective no later than the first day of the second month following the month that includes the date coverage is revoked; or

■ you become eligible to enroll in a qualified health insurance plan offered through the Marketplace during a Special Enrollment period or annual open enrollment period for the Marketplace, provided you represent that you have enrolled or intend to enroll yourself and your applicable dependents in such a qualified health insurance plan through the Marketplace and your new coverage is effective beginning no later than the day immediately following the last day you and your applicable dependents have coverage under the plan.

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You are not allowed to drop your coverage other than during the Annual Enrollment period unless you have a Change in Status.

For more information, go to myHR at myhr.cvs.com or call myHR at 1-888-MY-HR-CVS (1-888-694-7287). If you believe you are eligible to make a mid-year election change due to a Change in Status described above, go to myHR at myhr.cvs.com and make your enrollment change within 30 days of the date of the event (except in the case of a birth or adoption, in which case you have 60 days to make your enrollment change).

Coverage for Members Who are Hospitalized on Their Effective Date

If you are in the hospital on your effective date of coverage, health care services related to such hospitalization are covered provided that the health care services are received in accordance with the terms, conditions, exclusions and limitation of the plan. Please notify the Claims Administrator of your hospitalization within forty-eight (48) hours of the effective date, or as soon as is reasonably possible. As always, benefits paid in such situations are subject the Coordination Benefits provision outlined in this SPD.

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15 SECTION 3 - HOW THE PLAN WORKS

SECTION 3 – HOW THE HSP WORKS

This section describes how the HSP works and how to make the most of your coverage when you need care. You’ll find information about sharing the cost of your care, choosing a provider, certain important plan rules and requirements, and how a Health Savings Account works with the plan to pay for eligible health care expenses—now or anytime in the future.

Overview of the Health Savings Plan (HSP)

The HSP is a qualified high-deductible health plan that can be linked with a Health Savings Account (HSA) to help you pay for your eligible medical expenses (includes prescription drug expenses). Under the HSP, you share in the cost of your medical care by paying Deductible and Coinsurance, as shown and explained further below.

Here’s an overview of your coverage under the three HSP options:

Feature In-Network Out-of-Network

Deductible

Combined deductible applies to medical expenses and prescription drug expenses through the CVS Caremark prescription drug program

■ HSP Option 1 Individual coverage: $1,500Family coverage: $3,000

Individual coverage: $3,000 Family coverage: $6,000





Out-of-Pocket Maximum*

Combined out-of-pocket maximum includes the deductible and applies to medical expenses and prescription drug expenses through the CVS Caremark prescription drug program







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Feature In-Network Out-of-Network

Coinsurance

■ All HSP Options Plan pays 80% after the deductible is met

You pay 20% after the deductible until out-of-pocket maximum is met

Plan pays 50% after the deductible is met

You pay 50% after the deductible until out-of-pocket maximum is met

*Once one person in the family meets the individual out-of-pocket maximum, all covered medical and prescriptions for that individual in the family will be covered at 100% for the rest of the Plan Year.

Under the HSP, medical and prescription drug expenses both count toward the Deductible and Out-of-Pocket Maximum. Please note, however, that:

■ In-Network preventive medical care and all preventive generic drugs on the HSP Preventive Therapy Drug List which are covered at 100%.

■ For preventive brand drugs on the HSP Preventive Therapy Drug List, the Deductible is waived and you pay 20% of the full discounted cost in Coinsurance; the amount you pay in Coinsurance goes toward the Out-of-Pocket Maximum.

■ Specialty drugs on the HSP Preventive Therapy Drug List are covered at a $100 copayment and are not subject to the deductible.

■ All other specialty drugs are covered at a $100 copayment after the deductible is met.

Even though CVS Caremark administers your prescription drug coverage, your non-preventive prescription drug expenses count toward your medical option’s Annual Deductible and Out-of-Pocket Maximum.

Further, if you’re covering yourself and any Dependents, you must reach the full amount of the family Deductible before the plan pays benefits at 80% for In-Network care or 50% for Non-Network care (unless the Deductible doesn’t apply—such as for in-network preventive medical care and preventive medications).

Overview of the Health Savings Account (HSA)

A Health Savings Account (HSA) is a special savings account that lets you set aside money to pay for eligible health care expenses — now or anytime in the future. The HSA is an interest-bearing account that you can fund with pre-tax contributions made through payroll deduction or directly through the HSA Administrator, ConnectYourCare.

You may open your HSA when you enroll in the Health Savings Plan; however, you cannot open an HSA if:

■ You are enrolled in Medicare;

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■ You are covered by any other health care plan, including a Health Reimbursement Account or Flexible Spending Account; or

■ You can be claimed as a dependent on someone else’s federal tax return, except for your legal spouse.

Contributing to your HSA You and CVS may contribute to your HSA. For 2016/2017, CVS will make a tax-free contribution to your HSA based on your annual base salary and whether you cover yourself only or yourself and any dependent, as noted in the following chart:

Annual Contribution

Annual Base Salary Individual Family

$35,000 or less $1,000 $2,000

$35,001 – $80,000 $750 $1,500

$80,001 – $150,000 $500 $1,000

Greater than $150,000 $250 $500

Note: Annual contributions shown are for enrollment for the full plan year of June 1 through May 31.

Keep in Mind To receive the CVS contribution, you must open your HSA with ConnectYourCare, the HSA Administrator for CVS, when you enroll in the HSP. HSA Bank is the custodial bank that ConnectYourCare partners with for your HAS account. Opening an HSA is quick and easy to do, and you don’t need to make a deposit to open an account. You can also open an HSA with another institution instead of ConnectYourCare; however, you will not be able to receive CVS contributions or make pre-tax payroll contributions unless you have an open ConnectYourCare HSA.

For the 2016 calendar year, the Internal Revenue Service (IRS) limits annual HSA contributions to $3,350 for individuals and $6,750 for families. Annual limits are indexed and increased each year. For 2017, the limits are $3,400 for individuals and $6,750 for families. Also, starting in the year in which you turn age 55, you can also make up to an extra $1,000 annual catch-up contribution.

There is no “use it or lose it” rule that applies to your HSA, so any balance left at the end of the year remains in your HSA, available for future expenses.

Using Your Account When you have qualified health care expenses, you can pay the expenses out of pocket and save your HSA funds for future expenses. Or you can pay for the expenses using your HSA funds.

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Qualified health care expenses are defined by the IRS and include your medical plan deductible and coinsurance payments. You can also use fund to pay for other qualified health-related care such as out-of-pocket dental and vision expenses.

A complete list of HSA-qualified health care expenses can be found at www.irs.gov. Click on “Forms and Publications,” then select IRS Publication 969, Health Savings Accounts and Other Tax-Favored Health Plans, and IRS Publication 502, Medical and Dental Expenses.

You should consult your tax adviser if you have any questions about qualified health care expenses or your HSA.

Keep in Mind A Health Savings Account (HSA) is not considered a health and welfare plan and is not subject to ERISA requirements. The information in this booklet about the HSA is provided to help you understand how the HSA works but is not an SPD for the HSA.

Health Savings Plan Features

Eligible Expenses Eligible Expenses are charges for Covered Health Services that are provided while the Plan is in effect, determined according to the definition in Section 15, Glossary. For certain Covered Health Services, the Plan will not pay these expenses until you have met your Annual Deductible. CVS has delegated to UnitedHealthcare the discretion and authority to decide whether a treatment or supply is a Covered Health Service and how the Eligible Expenses will be determined and otherwise covered under the plan.

Deductible The Deductible is the part of Eligible Expenses you pay each plan year before the Plan starts to pay benefits. There are two levels of Deductible:

■ Employee only (Individual): If you elect coverage for yourself only, you must meet the Individual Deductible, shown under the Overview of the Health Savings Plan (HSP) before the plan begins to pay benefits each plan year.

■ Family: If you elect coverage for yourself and one or more Dependents, you must meet the Family Deductible shown under the Overview of the Health Savings Plan (HSP). The Plan begins to pay benefits once the combined Deductible expenses of all family members reaches the Family Deductible.

The HSP has separate Deductibles for Network and non-Network care:

■ Expenses that apply to the Network Deductible do not apply toward the non-Network Deductible.

■ Expenses that apply to the non-Network Deductible do not apply toward the Network Deductible.

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Coinsurance Once you meet your Deductible, the HSP begins paying benefits for Eligible Expenses. The portion paid by the HSP, as shown in the Overview of the Health Savings Plan (HSP) and Medical Plan Highlights, is the plan’s Coinsurance. When the plan’s Coinsurance is less than 100%, you pay the balance. The part you pay is called your Coinsurance.

The HSP has different Coinsurance levels for Network and non-Network care for each type of covered expense, as reflected in charts contained in the Medical Plan Highlights section of this SPD.

Out-of-Pocket Maximum The HSP puts a limit on the amount you pay for Eligible Expenses out of your own pocket each year, called the Out-of-Pocket Maximum. It includes your Deductible and any money you paid in Coinsurance. It does not include your paycheck deductions for coverage:

■ Employee-only (Individual): The Individual Out-of-Pocket Maximum applies separately to each covered person. Once an individual reaches the Individual Out-of-Pocket Maximum, the HSP pays 100% of that person’s covered expenses for the rest of the Plan Year.

■ Family: The Family Out-of-Pocket Maximum applies to the family as a group. If you cover someone besides yourself, here’s how your HSP option’s Family Out-of-Pocket Maximum will work:

■ Once a covered family member reaches the Individual Out-of-Pocket Maximum, the HSP will pick up 100% of the cost of Eligible Expenses for that family member for the rest of the Plan Year. No further expenses for that individual family member will apply to the Family Out-of-Pocket Maximum.

■ Eligible Expenses for all remaining covered family members will continue to count toward the Family Out-of-Pocket Maximum.

Following is an example of how the Out-of-Pocket Maximum operates for a family:

Colleague enrolled in HSP 1 with $3,000 family Deductible and $3,000 per individual Out-of-Pocket Maximum (up to $6,000 family limit). Example assumes all expenses are incurred in network.

Satisfying the $3,000 family Deductible

■ Member 1 accumulates $1,000 of expenses towards the family Deductible

■ Member 2 accumulates $1,500 of expenses towards the family Deductible

■ Member 3 accumulates $500 of expenses towards the family Deductible

Satisfying the $3,000 / $6,000 Out-of-Pocket Maximums

■ Member 2 incurs a $10,000 claim; 80% coinsurance applies – Member pays $1,500; individual Out-of-Pocket Maximum is met

- $10,000 x 20% member Coinsurance = $2,000

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- $1,500 of individual expenses incurred towards family Deductible + $2,000 = $3,500 > $3,000 per individual Out-of-Pocket Maximum

- Member pays $1,500 (total of $3,000 in expenses) and satisfies the maximum; plan pays remainder of claim and future expenses incurred by this family member

- $3,000 family Deductible + $1,500 = $4,500 < $6,000 family Out-of-Pocket Maximum limit

■ Then, Member 1 incurs a $2,000 claim; 80% Coinsurance applies – Member pays $400; neither individual or family Out-of-Pocket Maximum are met

- $2,000 x 20% member Coinsurance = $400

- $1,000 of individual expenses incurred towards family Deductible + $400 = $1,400 < $3,000 per individual Out-of-Pocket Maximum

- $4,500 of family expenses incurred + $400 = $4,900 < $6,000 family Out-of-Pocket Maximum limit

■ Then, Member 3 incurs a $7,500 claim; 20% Coinsurance applies – Member pays $1,100; family Out-of-Pocket Maximum is met

- $7,500 x 20% member coinsurance = $1,500

- $500 of individual expenses incurred towards family Deductible + $1,500 = $2,000 < $3,000 per individual Out-of-Pocket Maximum

- $4,900 of family expenses incurred + $1,500 = $6,400 > $6,000 family Out-of-Pocket Maximum limit

- Member pays $1,100 and the family maximum is satisfied; plan pays remainder of family’s expenses

Both medical and Caremark prescription drug plan expenses are applied to the Out-of-Pocket Maximum. The HSP has separate Out-of-Pocket Maximums for Network and non-Network care:

■ Expenses that apply to the Network Out-of-Pocket Maximum do not apply toward the non-Network Out-of-Pocket Maximum.

■ Expenses that apply to the non-Network Out-of-Pocket Maximum do not apply toward the Network Out-of-Pocket Maximum.

Certain expenses do not apply toward the Out-of-Pocket Maximum:

■ Expenses that exceed Eligible Expenses;

■ Penalties, including any additional out-of-pocket expenses you pay because you did notify Personal Health Support; and

■ Charges for non-Covered Health Services.

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A Qualifying Event May Affect Your Plan Deductible and Out-of-Pocket Maximum

Change from Individual to Family Coverage ■ If you enroll in the HSP for Employee Only (Individual) coverage and later experience a

qualifying event during the plan year that results in you adding one or more dependents, your coverage level, Deductible and Out-of-Pocket Maximum will change from Individual to Family. When the change to Family coverage occurs, amounts you met toward your Individual Deductible and Out-of-Pocket Maximum (as of the date of the change) will be applied to your new Family Deductible and Out-of-Pocket maximum. As of the date of the change, your claims will begin to apply toward meeting your Family Deductible and Out-of-Pocket Maximum.

Change from Family to Individual Coverage ■ If you enroll in the HSP for Family coverage and cover yourself and one or more

dependents and later experience a qualifying event during the plan year that results in you dropping all your covered dependents from coverage, your coverage level, Deductible and Out-of-Pocket Maximum will change from Family to Individual. When this happens, only your individual expenses incurred while you were enrolled in Family coverage will apply to your new Individual Deductible and Out-of-Pocket Maximum. Your dependents’ expenses that were applied to the Family Deductible will not count towards your new Individual Deductible and Out-of-Pocket maximum, except in the event of death as described below.

Example of Family to Individual Coverage: ■ A mother and child are enrolled in the HSP 1 with Family coverage which has a Family

deductible of $3,000.

- The mother has accumulated $1,000 towards their Family plan deductible

- The child has accumulated $500 towards the Family plan deductible

- Together, they have satisfied $1,500 towards the Family plan deductible

■ If the child has a qualifying event and is no longer eligible for dependent coverage, the mother’s plan will change from Family coverage to Individual coverage, and as a result, only the $1,000 that she has accumulated will be credited to her Individual plan deductible. The $500 accumulated by her child will not be credited to her individual plan deductible.

Network and Non-Network Benefits

As a participant in this plan, you have the freedom to choose the Physician or health care professional you prefer each time you need to receive Covered Health Services. The choices you make affect the amounts you pay, as well as the level of Benefits you receive and any benefit limitations that may apply.

You are eligible for the Network level of Benefits under this plan when you receive Covered Health Services from Physicians and other health care professionals who have contracted with UnitedHealthcare or Harvard Pilgrim Health Care to provide those services.

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Generally, when you receive Covered Health Services from a Network Provider, you pay less than you would if you receive the same care from a non-Network Provider. Therefore, in most instances, your out-of-pocket expenses will be less if you use a Network Provider.

If you choose to seek care outside the Network, the plan generally pays Benefits at a lower level. You are required to pay the amount that exceeds the Eligible Expense. The amount in excess of the Eligible Expense could be significant, and this amount does not apply to the Out-of-Pocket Maximum. You may want to ask the non-Network Provider about their billed charges before you receive care. Emergency services received at a non-Network Hospital are covered at the Network level.

Employees who live in New Hampshire (and their covered Dependents regardless of where those Dependents live) will receive Network coverage through the Harvard Pilgrim Health Care network when seeking covered health services in New Hampshire or through the UnitedHealthcare network when seeking covered health services outside New Hampshire.

Employees who live outside New Hampshire (and their covered Dependents regardless of where those Dependents live) will receive Network coverage through the UnitedHealthcare network.

Looking for a Network Provider? In addition to other helpful information, www.myuhc.com, UnitedHealthcare's consumer website, contains a directory of health care professionals and facilities in UnitedHealthcare's Network. While Network status may change from time to time, www.myuhc.com has the most current source of Network information. Use www.myuhc.com to search for Physicians available in your plan.

Network Providers UnitedHealthcare or its affiliates arrange for health care Providers to participate in a Network. At your request, UnitedHealthcare will send you a directory of Network Providers free of charge. Keep in mind, a Provider's Network status may change. To verify a Provider's status or request a Provider directory, you can call UnitedHealthcare at the toll-free number on your ID card or log onto www.myuhc.com.

Network Providers are independent practitioners and are not employees of CVS or UnitedHealthcare.

UnitedHealthcare's credentialing process confirms public information about the providers' licenses and other credentials, but does not assure the quality of the services provided.

Possible Limitations on Provider Use If UnitedHealthcare determines that you are using health care services in a harmful or abusive manner, you may be required to select a Network Physician to coordinate all of your future Covered Health Services. If you don't make a selection within 30 days of the date you are notified, UnitedHealthcare will select a Network Physician for you. In the event that you do not use the Network Physician to coordinate all of your care, any Covered Health Services you receive will be paid at the non-Network level.

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Health Care Reform Notice – Choice of Provider

UnitedHealthcare generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in UnitedHealthcare’s Network and who is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact UnitedHealthcare at the number on the back of your ID card.

For children, you may designate a pediatrician as the primary care provider.

You do not need prior authorization from UnitedHealthcare or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in UnitedHealthcare’s network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact UnitedHealthcare at the number on the back of your ID card.

Coverage While Traveling Outside the United States

The plan pays Benefits for Covered Persons if you become sick or injured while traveling outside the United States (U.S.) and need urgent or emergency care. There are no network providers outside the U.S. However, Covered Health Services for urgent or emergency care received outside the United States will be paid at the Network benefit level and are subject to the Deductible. Eligible Expenses for non-Emergency services incurred while outside the United States are reimbursed at the non-Network benefit level and are subject to the Deductible. You must pay the provider at the time treatment is received and obtain appropriate documentation of services received including any bills, receipts and medical narrative. This information should be included when you submit your claim to UnitedHealthcare as described in Section 9, Claims Procedures. If you have any questions about Benefits while traveling abroad, or before you travel, please call UnitedHealthcare at the toll-free number on your ID card.

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24 SECTION 4 – PERSONAL HEALTH SUPPORT

SECTION 4 – PERSONAL HEALTH SUPPORT

What This Section Includes: ■ An overview of the Personal Health Support program; and

■ Covered Health Services for which you need to contact Personal Health Support.

UnitedHealthcare and CVS provides a program called Personal Health Support designed to encourage personalized, efficient care for you and your covered Dependents.

Personal Health Support Nurses center their efforts on prevention, education, and closing any gaps in your care. The goal of the program is to ensure you receive the most appropriate and cost-effective services available. A Personal Health Support Nurse is notified when you or your Provider calls the toll-free number on your ID card regarding an upcoming treatment or service.

If you are living with a chronic condition or dealing with complex health care needs, UnitedHealthcare may assign to you a primary nurse, referred to as a Personal Health Support Nurse to guide you through your treatment. This assigned nurse will answer questions, explain options, identify your needs, and may refer you to specialized care programs. The Personal Health Support Nurse will provide you with their telephone number so you can call them with questions about your conditions, or your overall health and well-being.

Personal Health Support Nurses will provide a variety of different services to help you and your covered family members receive appropriate medical care. Program components and notification requirements are subject to change without notice. As of the publication of this SPD, the Personal Health Support program includes:

■ Admission counseling - Nurse advocates are available to help you prepare for a successful surgical admission and recovery. Call the number on the back of your ID card for support with any questions and/or information.

■ Inpatient care management - If you are hospitalized, a nurse will work with your Physician to make sure you are getting the care you need and that your Physician's treatment plan is being carried out effectively.

■ Readmission Management - This program serves as a bridge between the Hospital and your home if you are at high risk of being readmitted. After leaving the Hospital, if you have a certain chronic or complex condition, you may receive a phone call from a Personal Health Support nurse to confirm that medications, needed equipment, or follow-up services are in place. The Personal Health Support Nurse will also share important health care information, reiterate and reinforce discharge instructions, and support a safe transition home.

■ Risk Management - Designed for participants with certain chronic or complex conditions, this program addresses such health care needs as access to medical specialists, medication information, and coordination of equipment and supplies. Participants may receive a phone call from a Personal Health Support Nurse to discuss

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and share important health care information related to the participant's specific chronic or complex condition.

If you do not receive a call from a Personal Health Support nurse but feel you could benefit from any of these programs, please call the toll-free number on your ID card.

Prior Authorization

UnitedHealthcare requires prior authorization for certain Covered Health Services. 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. Services for which prior authorization is required are identified below and in Section 6, Additional Coverage Details within each Covered Health Service category.

It is recommended that you confirm with UnitedHealthcare 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 UnitedHealthcare to verify that the Hospital, Physician and other providers are Network providers and that they have obtained the required prior authorization. Network facilities and Network providers cannot bill you for services they fail to prior authorize as required. You can contact UnitedHealthcare by calling the toll-free telephone number on the back of 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.

To obtain prior authorization, call the toll-free telephone number on the back of your ID card. This call starts the utilization review process. Once you have obtained the authorization, please review it carefully so that you understand what services have been authorized and what providers are authorized to deliver the services that are subject to the authorization.

The utilization review process is a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or settings. Such techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, retrospective review or similar programs.

Covered Health Services which Require Prior Authorization

Network providers are generally responsible for obtaining prior authorization from Personal Health Support before they provide certain services to you. However, there are some Network Benefits for which you may be responsible for obtaining prior authorization from Personal Health Support.

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When you choose to receive certain Covered Health Services from non-Network providers, you are responsible for obtaining prior authorization from Personal Health Support before you receive these services. In many cases, your Non-Network Benefits will be reduced if Personal Health Support has not provided prior authorization.

The Network and non-Network services that require prior authorization are:

■ Ambulance – non-emergent air.

■ Clinical Trials;

■ Chemotherapy services:

■ Congenital Heart Disease services;

■ Durable Medical Equipment for items that will cost more than $1,000 to purchase or rent, including diabetes equipment for the management and treatment of diabetes;

■ Genetic Testing – BRCA;

■ Home health care;

■ Hospice care - inpatient;

■ Hospital Inpatient Stay – all scheduled admissions;

■ Lab, x-ray and diagnostics – Outpatient – sleep studies;

■ Lab, x-ray and major diagnostics – CT, PET scans, MRI, MRA and Nuclear Medicine;

■ Maternity care that exceeds the delivery timeframes as described in Section 6, Additional Coverage Details;

■ Mental Health Services - inpatient services (including Partial Hospitalization/Day Treatment and services at a Residential Treatment Facility); intensive outpatient program treatment; outpatient electro-convulsive treatment; psychological testing; extended outpatient treatment visits beyond 45 - 50 minutes in duration, with or without medication management;

■ Neurobiological Disorders - Autism Spectrum Disorder Services -inpatient services (including Partial Hospitalization/Day treatment and services at a Residential Treatment Facility); intensive outpatient program treatment; outpatient electro-convulsive treatment; psychological testing; extended outpatient treatment visits beyond 45 - 50 minutes in duration, with or without medication management;

■ Reconstructive Procedures, including breast reconstruction surgery following mastectomy;

■ Skilled Nursing Facility/Inpatient Rehabilitation Facility Services;

■ Substance-Related and Addictive Disorder Services - inpatient services (including Partial Hospitalization/Day Treatment and services at a Residential Treatment Facility); intensive outpatient program treatment; outpatient electro-convulsive treatment; psychological testing; extended outpatient treatment visits beyond 45 - 50 minutes in duration, with or without medication management;

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■ Surgery – cardiac catheterization, pacemakers insertion, implantable cardiovascular defibrillators, diagnostic catheterization and electrophysiology implant and sleep apnea surgeries as described under Surgery - Outpatient in Section 6, Additional Coverage Details;

■ Therapeutics - outpatient dialysis treatments, intensity modulated radiation therapy and MR-guided focused ultrasound as described under Therapeutic Treatments - Outpatient in Section 6, Additional Coverage Details; and

■ Transplantation services.

Notification is required within two business days after admission or on the same day of admission if reasonably possible after you are admitted to a non-Network Hospital as a result of an Emergency.

When you choose to receive services from non-Network providers, UnitedHealthcare urges you to confirm with Personal Health Support that the services you plan to receive are Covered Health Services. That's because in some instances, certain procedures may not 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 such as:

■ the cosmetic procedures exclusion. Examples of procedures that may or may not be considered cosmetic include: breast reduction and reconstruction (except for after cancer surgery when it is always considered a Covered Health Service); vein stripping, ligation and sclerotherapy, and upper lid blepharoplasty;

■ the experimental, investigational or unproven services exclusion; or

■ any other limitation or exclusion of the plan.

For prior authorization timeframes, and reductions in Benefits that apply if you do not notify Personal Health Support, see Section 6, Additional Coverage Details.

Contacting Personal Health Support is easy. Simply call the toll-free number on your ID card.

Special Note Regarding Medicare

If you are enrolled in Medicare on a primary basis and Medicare pays benefits before the plan, you are not required to notify Personal Health Support before receiving Covered Health Services. Since Medicare pays benefits first, this plan will pay Benefits second as described in Section 10, Coordination of Benefits (COB).

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28 SECTION 5 - MEDICAL PLAN HIGHLIGHTS

SECTION 5 – MEDICAL PLAN HIGHLIGHTS

Services are covered as follows for all three HSP options (see How the Plan Works section for details on deductible and OOP maximums). Any benefit maximums apply to Network and Non-Network services combined. For additional information on your Benefits, including any additional limitations that may apply, as well as Covered Health Services which require prior authorization, refer to Section 6, Additional Coverage Details.

Covered Health Services1

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network

Ambulance Services - Emergency Only 80% after Deductible

80% after Network Deductible

Ambulance Services - Non-Emergency

Note: Non-Emergency transportation that is not approved is not covered (see Section 6 for details).

80% after Deductible 80% Deductible

Blood Transfusions 80% after Deductible

50% after Deductible

Cancer Resource Services (CRS)2

■ Hospital Inpatient Stay 80% after Deductible Not Covered

Clinical Trials - Routine Patient Care Costs

Depending upon where the Covered Health Service is provided, Benefits for Clinical

Trials will be the same as those stated under each Covered Health Service category in

this section.

Congenital Heart Disease (CHD) 80% after Deductible


Dental Services - Accident Only 80% after Deductible


Diabetes Services Depending upon where the Covered Health Service is provided, Benefits for diabetes

self-management and training/diabetic eye examinations/foot care will be paid the

same as those stated under each Covered Health Service category in this section.

■ Diabetes Self-Management and Training/ Diabetic Eye Examinations/Foot Care

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Network Non-Network

Note: Benefits for diabetes education are covered at Coinsurance level, depending on network usage, after you meet the Annual Deductible, and are limited to one-pre-assessment visit, 5 individual visits and 7 group sessions per Plan Year (per

Covered Person).

■ Diabetes Self-Management Items

- diabetes equipment - diabetes supplies

Benefits for diabetes equipment will be the same as those stated under Durable Medical

Equipment in this section.

See Durable Medical Equipment in Section 6, Additional Coverage Details, for limits.

Dialysis 80% after Deductible


Durable Medical Equipment (DME) 80% after Deductible


Emergency Health Services

Note: Must be to treat a condition that meets the definition of an Emergency; otherwise, services will not be covered.


80% after Network Deductible

Enteral Nutrition 80% after Deductible


Family Planning

■ Voluntary Sterilization (men) 80% after Deductible


■ Voluntary Sterilization (women) 100% 50% after Deductible

■ Contraceptive Counseling 100% Not Covered

■ Contraceptive Devices and Injectables provided by and billed by Physician

100% Not Covered

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Network Non-Network

Gender Identity Disorder Treatment

Up to $75,000 per member lifetime maximum (Network and Non-Network Benefits combined)



Hearing Exams

1 routine exam per Plan year

80% after Deductible Not Covered

Home Health Care

Up to 80 visits per Plan year



Hospice Care

Note: Benefits available only when care is received from a licensed hospice agency (which can include a Hospital).



Hospital - Inpatient Stay 80% after Deductible


Infertility Services and Reproductive Resource Services (RRS) Program

■ Physician's Office Services 80% after Deductible


■ Outpatient services received at a Hospital or Alternate Facility



Up to $10,000 per lifetime per Covered Person (Network and Non-Network Benefits combined)

See Infertility Services and Reproductive Resource Services (RRS) Program in Section 6 – Additional Coverage Details, for more details and limits.

Injections in a Physician's Office Allergy injections/ serum

80%, no Deductible

All other injections 80% after Deductible


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Network Non-Network

Lab, X-Ray and Diagnostics – Outpatient 80% after Deductible


Lab, X-Ray and Major Diagnostics - CT, PET, MRI, MRA and Nuclear Medicine – Outpatient



Mental Health Services

■ Hospital/ Inpatient Care (includes Partial Hospitalization/Day Treatment and services at a Residential Treatment Facility)



■ Outpatient Care/Physician's Office Services (includes Intensive Outpatient Treatment)



Neurobiological Disorders - Autism Spectrum Disorders







Nutritional Counseling

Maximum of 6 visits per year if non-preventive; see Nutritional Counseling in Section 6, Additional Coverage Details, for additional information on limits.



Obesity Surgery

■ Physician's Office Services 80% after Deductible Not Covered

■ Physician Fees for Surgical and Medical Services

80% after Deductible Not Covered

■ Hospital - Inpatient Stay

Up to 1 surgery per lifetime 80% after Deductible Not Covered

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Network Non-Network

Note: Obesity surgery is only covered when services are rendered at a Bariatric Resource Services (BRS) Designated Facility by a Network Surgeon.

See Section 6, Additional Coverage Details for additional information on limits.

Ostomy Supplies

See Section 6, Additional Coverage Details for limitations.



Physician Fees for Surgical and Medical Services



Physician Office Services (Non-Preventive)

■ Primary or Specialist Physician 80% after Deductible


Pregnancy – Maternity Services 3

Physician's Office Services – prenatal and postnatal care visits, (including services of a licensed midwife).

Note: The initial office visit (to diagnose pregnancy) is not included in prenatal services.

■ Initial Visit to confirm pregnancy 80% after Deductible


■ Routine prenatal visits 100% 50% after Deductible

■ Delivery and postnatal care 80% after Deductible


■ Hospital - Inpatient Stay 80% after Deductible


■ Physician Fees for Surgical and Medical Services (includes delivery)



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Network Non-Network

Preventive Care Services

■ Physician Office Services 100% Not Covered except for travel immunizations,

which are covered at 100%

■ Lab, X-ray or Other Preventive Tests

See Section 6, Additional Coverage Details for additional information.

100%

Prosthetic Devices 80% after Deductible


Reconstructive Procedures

■ Physician's Office Services 80% after Deductible


■ Hospital - Inpatient Stay 80% after Deductible


■ Physician Fees for Surgical and Medical Services



Rehabilitation Services - Outpatient Therapy

(Includes physical, occupational and speech therapy, for which there are limits on the number of visits.)

See Section 6, Additional Coverage Details, for visit limits.


50% after Annual Deductible

Scopic Procedures - Outpatient Diagnostic and Therapeutic



Skilled Nursing Facility/Inpatient Rehabilitation Facility Services

Up to 120 days per Plan year



Spinal Treatment/Chiropractic Services

Up to 15 visits per Plan year. See Section 6, Additional Coverage Details, for visit limits.



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Network Non-Network

Substance-Related and Addictive Disorder Services







Surgery – Outpatient 80% after Deductible


Temporomandibular Joint Dysfunction (TMJ)



Therapeutic Treatments - Outpatient 80% after Deductible

50% after Annual Deductible

Transplantation Services

Note: Transplants are only covered when performed at a Designated Facility (except for Cornea Transplants). See Section 6, Additional Coverage Details for additional information on these Services.


Not Covered

Travel and Lodging

(If services rendered by a Designated Facility)

See Section 6, Additional Coverage Details for additional information on these Services.

For patient and companion(s) of patient undergoing cancer, Congenital Heart Disease treatment, bariatric surgery or

transplant procedures

Urgent Care Center Services 80% after Deductible


Virtual Visits

Network Benefits are available only when services are delivered through a Designated Virtual Network Provider. You can find a Designated Virtual Network Provider by going to www.myuhc.com or by calling the telephone number on your ID card.

80% after you meet the Network Deductible

Non-Network Benefits are not

available.

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1You must obtain prior authorization from Personal Health Support, as described in Section 4, Personal Health Support to receive full Benefits before receiving certain Covered Health Services from a non-Network Provider. In general, if you visit a Network Provider, that Provider is responsible for obtaining authorization from Personal Health Support before you receive certain Covered Health Services. See Section 6, Additional Coverage Details for further information.

2These Benefits are for Covered Health Services provided through CRS at a Designated Facility. For oncology services not provided through CRS, the Plan pays Benefits as described under Physician's Office Services, Physician Fees for Surgical and Medical Services, Hospital - Inpatient Stay, Surgery - Outpatient, Scopic Procedures - Outpatient Diagnostic and Therapeutic, Lab, X-Ray and Diagnostics – Outpatient, and Lab, X-Ray and Major Diagnostics – CT, PET, MRI, MRA and Nuclear Medicine – Outpatient. 3The benefits shown are for routine maternity care and services provided by your OB/GYN, including routine prenatal care, delivery services and postnatal care. Additional services such as laboratory tests and care that is required due to complications of pregnancy are not considered routine maternity care.

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36 SECTION 6 – ADDITIONAL COVERAGE DETAILS

SECTION 6 - ADDITIONAL COVERAGE DETAILS

What This Section Includes: ■ Covered Health Services for which the plan pays Benefits; and

■ Covered Health Services that require you to obtain prior authorization from Personal Health Support before you receive them, and any reduction in Benefits that may apply if you do not call Personal Health Support.

This section supplements the second table in Section 5, Medical Plan Highlights.

While the table provides you with benefit limitations along with Coinsurance and Deductible information for each Covered Health Service, this section includes descriptions of the Benefits. These descriptions include any additional limitations that may apply, as well as Covered Health Services for which you must call Personal Health Support. The Covered Health Services in this section appear in the same order as they do in the table for easy reference. Services that are not covered are described in Section 8, Exclusions.

Ambulance Services - Emergency Only

The HSP covers Emergency ambulance services and transportation provided by a licensed ambulance service to the nearest Hospital that offers Emergency Health Services. See Section 15, Glossary for the definition of Emergency.

Ambulance service by air is covered in an Emergency if ground transportation is impossible, or would put your life or health in serious jeopardy. If special circumstances exist, UnitedHealthcare may pay Benefits for Emergency air transportation to a Hospital that is not the closest facility to provide Emergency Health Services.

Ambulance Services - Non-Emergency

The HSP also covers transportation provided by a licensed professional ambulance, other than air ambulance, (either ground or air ambulance, as United Healthcare determines appropriate) between facilities when the transport is:

■ 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; or

■ from an acute facility to a sub-acute setting.

In most cases, UnitedHealthcare will initiate and direct non-Emergency ambulance transportation. If you are requesting non-Emergency ambulance services, please remember you must notify UnitedHealthcare as soon as possible prior to the transport. If Personal Health Support is not notified, Non-Network Benefits will be subject to a $500 reduction.

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Blood Transfusions

The HSP covers autologous or directed blood donation prior to a scheduled surgery when it generally requires blood transfusions and the provider/organization that obtains and processes the blood makes a charge that a patient is legally obligated to pay.

The following are some examples of procedures, if they involve major blood volume loss, that might require autologous blood transfusions or the use of autotransfusers:

■ emergency hemorrhage;

■ orthopedic surgery;

■ cardiac bypass surgery;

■ vascular femoral grafts’

■ hysterectomy and ectopic pregnancy;

■ post-operative hemorrhage; and

■ organ transplantation.

Cancer Resource Services (CRS)

The HSP pays Benefits for oncology services provided by Designated Facilities participating in the Cancer Resource Services (CRS) program. Designated Facility is defined in Section 15, Glossary.

For oncology services and supplies to be considered Covered Health Services, they must be provided to treat a condition that has a primary or suspected diagnosis relating to cancer. If you or a covered Dependent has cancer, you may:

■ be referred to CRS by a Personal Health Support Nurse;

■ call CRS toll-free at (866) 936-6002; or

■ visit www.urncrs.com.

To receive Benefits for a cancer-related treatment, you are not required to visit a Designated Facility. If you receive oncology services from a facility that is not a Designated Facility, the plan pays Benefits as described under:

■ Physician's Office Services;

■ Physician Fees for Surgical and Medical Services;

■ Scopic Procedures - Outpatient Diagnostic and Therapeutic;

■ Therapeutic Treatments - Outpatient;

■ Hospital - Inpatient Stay; and

■ Surgery - Outpatient.

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Note: The services described under Travel and Lodging are Covered Health Services only in connection with cancer-related services received at a Designated Facility.

To receive Benefits under the CRS program, you must contact CRS prior to obtaining Covered Health Services. The plan will only pay Benefits under the CRS program if CRS provides the proper authorization to the Designated Facility Provider performing the services (even if you self refer to a Provider in that Network).

Clinical Trials - Routine Patient Care Costs

Benefits are available for routine patient care costs incurred during participation in a qualifying Clinical Trial for the treatment of cancer or other life-threatening disease or condition. For purposes of this benefit, a life-threatening disease or condition is one from which the likelihood of death is probable unless the course of the disease or condition is interrupted.

Benefits include the reasonable and necessary items and services used to prevent, diagnose and treat complications arising from participation in a qualifying Clinical Trial. Benefits are available only when the Covered Person is clinically eligible for participation in the qualifying Clinical Trial as defined by the researcher.

Routine patient care costs for qualifying Clinical Trials include:

■ Covered Health Services for which Benefits are typically provided absent a Clinical Trial;

■ Covered Health Services required solely for the provision of the Investigational item or service, the clinically appropriate monitoring of the effects of the item or service, or the prevention of complications; and

■ 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, except for:

- certain Category B devices, - certain promising interventions for patients with terminal illnesses; and - other items and services that meet specified criteria in accordance with

UnitedHealthcare’s medical policy guidelines.

■ items and services provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient.

■ a service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis; and

■ items and services provided by the research sponsors free of charge for any person enrolled in the trial.

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With respect to cancer or other life-threatening diseases or conditions, a qualifying Clinical Trial is a Phase I, Phase II, Phase III, or Phase IV Clinical Trial that is conducted in relation to the prevention, detection or treatment of cancer or other life-threatening disease or condition and which meets any of the following criteria in the bulleted list below.

■ federally funded trials where the study or investigation is approved or funded (which may include funding through in-kind contributions) by one or more of the following:

- National Institutes of Health (NIH). (Includes National Cancer Institute (NCI)) - Centers for Disease Control and Prevention (CDC) - Agency for Healthcare Research and Quality (AHRQ) - Centers for Medicare and Medicaid Services (CMS) - a cooperative group or center of any of the entities described above or the

Department of Defense or the Department of Veterans Affairs - a qualified non-governmental research entity identified in the guidelines issued by the

National Institutes of Health for center support grants; or - The Department of Veterans Affairs, the Department of Defense or the Department

of Energy as long as the study or investigation has been reviewed and approved through a system of peer review that is determined by the Secretary of Health and Human Services to meet both of the following criteria: ♦ comparable to the system of peer review of studies and investigations used by

the National Institutes of Health; and ♦ ensures unbiased review of the highest scientific standards by qualified

individuals who have no interest in the outcome of the review.

■ the study or investigation is conducted under an investigational new drug application reviewed by the U.S. Food and Drug Administration;

■ the study or investigation is a drug trial that is exempt from having such an investigational new drug application;

■ the Clinical Trial must have a written protocol that describes a scientifically sound study and have been approved by all relevant institutional review boards (IRBs) before participants are enrolled in the trial. UnitedHealthcare may, at any time, request documentation about the trial; or

■ 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 plan.

Please remember that you must obtain prior authorization from Personal Health Support as soon as the possibility of participation in a Clinical Trial arises. If authorization from Personal Health Support is not obtained, Benefits for Covered Health Services will be subject to a $500 reduction.

Congenital Heart Disease (CHD)

The HSP pays Benefits for Congenital Heart Disease (CHD) services ordered by a Physician and received at a CHD Resource Services program. Benefits include the facility charge and the charge for supplies and equipment. Benefits are available for the following CHD services:

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■ outpatient diagnostic testing;

■ evaluation;

■ surgical interventions;

■ interventional cardiac catheterizations (insertion of a tubular device in the heart);

■ fetal echocardiograms (examination, measurement and diagnosis of the heart using ultrasound technology); and

■ approved fetal interventions.

CHD services other than those listed above are excluded from coverage, unless determined by United Resource Networks or Personal Health Support to be proven procedures for the involved diagnoses. Contact United Resource Networks at (888) 936-7246 or Personal Health Support at the toll-free number on your ID card for information about CHD services.

If you receive Congenital Heart Disease services from a facility that is not a Designated Facility, the plan pays Benefits as described under:

■ Physician's Office Services;

■ Physician Fees for Surgical and Medical Services;

■ Scopic Procedures - Outpatient Diagnostic and Therapeutic;

■ Therapeutic Treatments – Outpatient;

■ Hospital - Inpatient Stay; and

■ Surgery - Outpatient.

Please remember for Non-Network Benefits, you must obtain prior authorization from United Resource Networks or Personal Health Support as soon as CHD is suspected or diagnosed. If authorization from United Resource Networks or Personal Health Support is not obtained, Benefits for Covered Health Services will be subject to a $500 reduction.

Note: The services described under Travel and Lodging are Covered Health Services only in connection with CHD services received at a Congenital Heart Disease Resource Services program.

Dental Services

Dental services are covered by the HSP when all of the following apply:

■ treatment is necessary because of accidental damage to a sound, natural tooth;

■ dental damage does not occur as a result of normal activities of daily living or extraordinary use of the teeth;

■ dental services are received from a Doctor of Dental Surgery or a Doctor of Medical Dentistry; and

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■ the dental damage is severe enough that initial contact with a Physician or dentist occurs within 72 hours of the accident.

Before the plan will cover treatment of an injured tooth, the dentist must certify that the tooth is virgin or unrestored, and that it:

■ has no decay;

■ has no filling on more than two surfaces;

■ has no gum disease associated with bone loss;

■ has no root canal therapy;

■ is not a dental implant; and

■ functions normally in chewing and speech.

Dental services for final treatment to repair the damage must be started within three months of the accident and completed within 12 months of the accident.

The plan also covers dental care (oral examination, X-rays, extractions and non-surgical elimination of oral infection) required for the direct treatment of a medical condition limited to:

■ dental services related to medical transplant procedures;

■ initiation of immunosuppressives (medication used to reduce inflammation and suppress the immune system); and

■ direct treatment of acute traumatic Injury, cancer or cleft palate.

Wisdom teeth extraction is covered when the teeth are partially or completely impacted in the jawbone, will not erupt through the gum, or cannot be removed without removing bone.

In addition, the plan covers dental implant surgery that is required due to loss of sound natural teeth resulting from treatment of dislocations, facial and oral wounds/lacerations, removal of cysts or tumors of the jaws or facial bones or other diseased tissues, or the result of previous therapeutic process for a Covered Medical Condition. The Plan will also cover implants due to the absence of teeth related to congenital defects and anomalies when they result in a functional impairment.

The HSP provides benefits for replacement of teeth as a result of a non-biting injury. Sound natural teeth are defined as teeth that were stable, functional, free from decay and advanced periodontal disease, and in good repair at the time of the accident or removal or loss due to disease conditions. A disease condition does not include periodontal disease, tooth decay, severe cavities, or general damage caused by biting or chewing. Charges to remove, repair, replace, restore, or reposition teeth lost or damaged in the course of biting or chewing are not covered medical expenses.

The HSP covers the replacement of teeth whether accomplished by fixed or removable prostheses or by surgical placement of a dental implant body. In situations where

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replacement of the tooth/teeth is accomplished by dental implants, the dental crown is also a covered medical expense. Dental implants required due to the removal of teeth due to periodontal therapies and subsequent oral rehabilitation are not covered under the medical plan. All other treatment options must be exhausted.

Diabetes Services

The HSP pays Benefits for the Covered Health Services identified below.

Covered Diabetes Services

Diabetes Self-Management and Training/Diabetic Eye Examinations/Foot Care

Benefits include outpatient self-management training for the treatment of diabetes, education and medical nutrition therapy services. These services must be ordered by a Physician and provided by appropriately licensed or registered healthcare professionals.

Benefits for diabetes education are limited to one pre-assessment visit, 5 individual visits and 7 group sessions per Covered Person per Plan Year.

Benefits under this section also include medical eye examinations (dilated retinal examinations) and preventive foot care for Covered Persons with diabetes.

Diabetes Self-Management Items

Diabetes equipment that meets the definition of Durable Medical Equipment is subject to the conditions of coverage stated under Durable Medical Equipment in this section.

Dialysis

The HSP covers charges for necessary medical services as well as hemodialysis equipment and supplies for hemodialysis administered to a patient with end-stage renal disease. Services must be provided in a Hospital-based or freestanding hemodialysis center.

Durable Medical Equipment (DME)

The HSP pays for Durable Medical Equipment (DME) that is:

■ ordered or provided by a Physician for outpatient use;

■ used for medical purposes;

■ not consumable or disposable;

■ not of use to a person in the absence of a Sickness, Injury or disability;

■ durable enough to withstand repeated use; and

■ appropriate for use in the home.

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If more than one piece of DME can meet your functional needs, you will receive Benefits only for the most Cost-Effective piece of equipment. Benefits are provided for a single unit of DME (example: one insulin pump) and for repairs of that unit.

Examples of DME include but are not limited to:

■ equipment to administer oxygen;

■ equipment to assist mobility, such as a standard wheelchair;

■ hospital beds;

■ delivery pumps for tube feedings;

■ burn garments;

■ insulin pumps and all related necessary supplies as described under Diabetes Services in this section;

■ external cochlear devices and systems. Surgery to place a cochlear implant is also covered by the plan. Cochlear implantation can either be an inpatient or outpatient procedure. See Hospital - Inpatient Stay, Rehabilitation Services - Outpatient Therapy and Surgery - Outpatient in this section;

■ custom manufactured or customer fitted orthotic appliances and devices, including foot orthotics and cranial bands, when prescribed by a Physician for a medical purpose;

■ braces that stabilize an injured body part, including necessary adjustments to shoes to accommodate braces when prescribed by a Physician for a medical purpose. 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. Dental braces are excluded from coverage; and

■ equipment for the treatment of chronic or acute respiratory failure or conditions.

The HSP also covers tubings, nasal cannulas, connectors and masks used in connection with DME.

Note: DME is different from prosthetic devices – see Prosthetic Devices in this section.

Benefits are provided for the repair/replacement of a type of Durable Medical Equipment once every three plan years.

At UnitedHealthcare's discretion, replacements are covered for damage beyond repair with normal wear and tear, when repair costs exceed new purchase price, if replacement is needed due to the Covered Person’s growth, or when a change in the Covered Person's medical condition occurs sooner than the three year timeframe. Repairs, including the replacement of essential accessories, such as hoses, tubes, mouth pieces, etc., for necessary DME are only covered when required to make the item/device serviceable and the estimated repair expense does not exceed the cost of purchasing or renting another item/device. Requests for repairs may be made at any time and are not subject to the three year timeline for replacement.

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Please remember for Non-Network Benefits, you must obtain prior authorization from Personal Health Support if the purchase, rental, repair or replacement of DME will cost more than $1,000. You must purchase or rent the DME from the vendor Personal Health Support identifies.

Emergency Health Services

The HSP covers Emergency Health Services provided in a Hospital Emergency room while a person is not a full-time inpatient; however, benefits are paid for Emergency Health Services only for an Emergency condition.

If you have an accident or medical Emergency that requires Emergency Health Services and your first visit to the Emergency room occurs within twenty-four (24) hours of the accident or onset of symptoms, the plan covers the Hospital or Emergency room services and the doctor’s services.

If you are admitted as an inpatient to a Network Hospital within 24 hours of receiving treatment for an Emergency Health Service, the Benefits for an Inpatient Stay in a Network Hospital will apply instead.

Network Benefits will be paid for an Emergency admission to a non-Network Hospital as long as Personal Health Support is notified within two business days of the admission or as soon as reasonably possible after you are admitted to a non-Network Hospital. If you continue your stay in a non-Network Hospital after the date your Physician determines that it is medically appropriate to transfer you to a Network Hospital, Non-Network Benefits will apply.

Note: Benefits under this section are not available for services to treat a condition that does not meet the definition of an Emergency.

Please remember you must notify Personal Health Support within two business days after admission, or on the same day of admission if reasonably possible, if you are admitted to a non-Network Hospital as a result of an Emergency. If Personal Health Support is not notified, Benefits for the Inpatient Hospital Stay will be subject to a $500 reduction.

Enteral Nutrition

The HSP covers enteral tube feedings when Medically Necessary to provide sufficient nutrients to maintain appropriate weight and strength for members if the enteral nutrition is the sole source of nutrition or is need due to an inborn error of metabolism.

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Family Planning

The HSP covers voluntary sterilization charges made by a Physician or Hospital for a vasectomy or tubal ligation. The plan does not cover the reversal of a sterilization procedure.

The plan covers the following contraceptive services and supplies when obtained from, and billed by, your Physician:

■ contraceptive counseling;

■ contraceptive devices prescribed by a Physician;

■ office visit for the injection of injectable contraceptives; and

■ related outpatient services such as consultations, exams and procedures.

Other contraceptives may be covered as part of the prescription drug program. Refer to the separate booklet describing the prescription drug coverage administered by Caremark for more information.

The Plan also covers elective and induced abortions, including multi-fetal pregnancy reductions (MFPR), and any services related to such procedures.


The Plan pays Benefits for the treatment of gender identify disorder as follows:

■ psychotherapy for gender identity disorders and associated co-morbid psychiatric diagnoses;

■ continuous hormone replacement - hormones of the desired gender;

■ surgery to change the genitalia and specified secondary sex characteristics, specifically:

- thyroid chondroplasty (reduction of the Adam's Apple); - bilateral mastectomy; and - augmentation mammoplasty if the Physician prescribing hormones and the surgeon

have documented that breast enlargement after undergoing hormone treatment for 18 months is not sufficient for comfort in the social role.

■ laboratory testing to monitor the safety of continuous hormone therapy.

The Covered Person must meet all of the following eligibility qualifications for hormone replacement (in addition to the plan’s overall eligibility requirements as shown in Section 2, Introduction):

■ age 18 years or older;

■ demonstrable knowledge of what hormones medically can and cannot do and their social benefits and risks;

■ the Covered Person must meet the definition of Gender Identity Disorder as shown in Section 14, Glossary; and

■ initial hormone therapy must be preceded by either:

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- a documented real-life experience of at least three months prior to the administration of hormones; or

- a period of psychotherapy of a duration specified by the mental health professional after the initial evaluation (usually a minimum of three months).

The Covered Person must meet all of the following eligibility qualifications for genital surgery and surgery to change secondary sex characteristics (in addition to the plan’s overall eligibility requirements as shown in Section 2, Introduction):

■ the surgery must be performed by a qualified provider at a facility with a history of treating individuals with gender identity disorder;

■ the treatment plan must conform to the World Professional Association for Transgender Health Association (WPATH) standards (please note that not all WPATH standards are covered under the plan. If you have questions, please call the number on your ID card.);

■ age 18 years or older;

■ has completed 12 months of continuous hormone therapy for those without contraindications;

■ has completed 12 months of successful continuous full time real life experience in the desired gender; and

■ your Physician who is performing the surgery must obtain prior authorization from the Claims Administrator prior to performing the surgery.

Hearing Exams

The HSP covers one (1) routine hearing exam per Plan Year. Routine hearing exams are covered when services are rendered by Network Physicians.

Home Health Care

Covered Health Services are services that a Home Health Agency provides if you need care in your home due to the nature of your condition. Services must be:

■ ordered by a Physician;

■ provided by or supervised by a registered nurse in your home, or provided by either a home health aide or licensed practical nurse and supervised by a registered nurse;

■ not considered Custodial Care, as defined in Section 15, Glossary; and

■ provided on a part-time, intermittent schedule when Skilled Care is required. Refer to Section 15, Glossary for the definition of Skilled Care.

Personal Health Support will decide if Skilled Care is needed 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.

Any combination of Network Benefits and Non-Network Benefits is limited to 80 visits per Plan Year. One visit equals four hours of Skilled Care services.

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Please remember for Non-Network Benefits, you must obtain prior authorization from Personal Health Support five business days before receiving services. If authorization from Personal Health Support is not obtained, Benefits will be subject to a $500 reduction.

Hospice Care

Hospice care is an integrated program recommended by a Physician which provides comfort and support services for the terminally ill. Hospice care can be provided on an inpatient or outpatient basis and 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 only when hospice care is received from a licensed hospice agency, which can include a Hospital.

Bereavement counseling Benefits are available to the immediate family if the Covered Person was receiving hospice care covered by the plan. To be covered, counseling must be received within six months after the Covered Person’s death.

Please remember for Non-Network Benefits, you must obtain prior authorization from Personal Health Support five business days before receiving services. If authorization from Personal Health Support is not obtained, Benefits will be subject to a $500 reduction.

Hospital - Inpatient Stay

Hospital Benefits are available for:

■ non-Physician services and supplies received during an Inpatient Stay; and

■ room and board in a Semi-private Room (a room with two or more beds).

The plan will pay the difference in cost between a Semi-private Room and a private room only if a private room is necessary according to generally accepted medical practice.

Benefits for an Inpatient Stay in a Hospital are available only when the Inpatient Stay is necessary to prevent, diagnose or treat a Sickness or Injury. Benefits for Hospital-based Physician services are described in this section under Physician Fees for Surgical and Medical Services.

Benefits for Emergency admissions and admissions of less than 24 hours are described under Emergency Health Services and Surgery - Outpatient, Scopic Procedures - Diagnostic and Therapeutic Services, and Therapeutic Treatments - Outpatient, respectively.

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Please remember for Non-Network Benefits for a:

■ scheduled admission, you must obtain prior authorization five business days before admission;

■ non-scheduled admission (including Emergency admissions), you must provide notification within two business days after admission, or on the same day of admission if reasonably possible.

If authorization is not obtained as required, or notification is not provided, Benefits will be subject to a $500 reduction.

Infertility Services and Reproductive Resources Services (RRS Program)

The HSP covers the diagnosis and treatment of the underlying cause of infertility, when provided by or under the direction of a physician. Benefits for infertility services are available to members as described further below. To be eligible for Benefits, the Covered Person must:

■ Have failed 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.

■ Have failed to achieve Pregnancy following six months of unsuccessful donor insemination.

■ Have failed to achieve Pregnancy due to impotence/sexual dysfunction.

■ Have diagnosis of a male factor causing infertility (e.g. treatment of sperm abnormalities including the surgical recovery of sperm).

■ Have infertility that is not related to voluntary sterilization or failed reversal of voluntary sterilization.

Covered Health Services for infertility services and associated expenses include:

■ Physician’s office visits and consultations.

■ Assisted Reproductive Technologies (ART): in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), and zygote intrafallopian transfer (ZIFT), and Intra Cytoplasmic Sperm Injection (ICSI).

■ Insemination procedures: Artificial Insemination (AI) and Intrauterine Insemination (IUI).

■ Embryo transport.

■ Ovulation induction and controlled ovarian stimulation.

■ Testicular Sperm Aspiration/Microsurgical Epididymal Sperm Aspiration (TESA/MESA) - male factor associated surgical procedures for retrieval of sperm.

■ Care of a person covered by the plan who is participating in a donor IVF program, including fertilization and culture.

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The HSP also covers the following:

■ The use of donor ovum and donor sperm which includes associated donor medical expenses, including collection and preparation of oocyte and/or sperm, and the medications associated with the collection and preparation or ovum and/or sperm. (Compensation and administration fees are not included).

■ Fertility preservation via IVF for employees and covered spouses that will undergo planned cancer or other medical treatments that are likely to result in infertility. The plan covers collection of sperm, ovulation induction, retrieval of eggs, IVF and cryopreservation (freezing only; storage is not covered)

■ For infertile male Covered Persons without a female partner, the HSP covers artificial insemination of a female carrier. If the female does not conceive following six cycles of insemination, no further coverage is provided unless a different surrogate is used, and then only for an additional six months of insemination with the male Covered Person’s sperm. The cost of any surrogate fees, as well as the cost of care associated with pregnancy, delivery and any complications, is not covered during the pregnancy/delivery.

The male related procedures described above are only available to males covered under the Plan.

Any combination of Network Benefits and Non-Network Benefits for infertility services is limited to $10,000 medical lifetime maximum per Covered Person under the Plan. There is a separate $10,000 prescription drug lifetime maximum Benefit for infertility services administered through the prescription drug plan administrator.

Reproductive Resource Services (RRS) Program The Benefits described under Infertility in this section are provided under the Reproductive Resource Services (RRS) program, as defined in Section 15, Glossary. Reproductive Resource Services (RRS) provides education, counseling, infertility management and access to a national Network of premier infertility treatment clinics.

You will have access to a certain Network of RRS Designated Facilities and Physicians participating in the Reproductive Resource Services program for infertility services.

You must enroll in RRS prior to receiving services in order to receive coverage for any infertility services. If you do not complete the enrollment process, no Benefits will be paid and you will be responsible for paying all charges, even if your health care provider or clinic is part of the Reproductive Resource Services network.

To enroll in the program and obtain information concerning infertility treatment, please contact a Reproductive Resource Services nurse at 1-866-774-4626.

Note: There is a 90 day “grace period” from the initial June 1, 2016 effective date to September 1, 2016 and claims will not be denied for failure to enroll in the RRS program. If infertility claims are denied after the initial grace period due to failure to enroll in the RRS

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program, services may be reconsidered for payment if enrollment in the program is completed within 90 days of your treatment service date.

Injections in a Physician's Office

Benefits are paid by the Plan for injections administered in the Physician's office, for example allergy immunotherapy, when no other health service is received.

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, but are not limited to:

■ lab and radiology/x-ray;

■ genetic testing; and

■ mammography.

Benefits for other Physician services are described in this section under Physician Fees for Surgical and Medical Services. Lab, X-ray and diagnostic services for preventive care are described under Preventive Care Services in this section.

Please remember for Non-Network Benefits for sleep studies, you must obtain prior authorization five business days before scheduled services are received. If authorization is not obtained as required, Benefits will be subject to a $500 reduction.

Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient

Services for CT scans, PET scans, MRI, MRA, nuclear medicine, and major diagnostic services received on an outpatient basis at a Hospital or Alternate Facility.

Benefits for other Physician services are described in this section under Physician Fees for Surgical and Medical Services.

Please remember for Non-Network Benefits you must obtain prior authorization five business days before scheduled services are received. If authorization is not obtained as required, Benefits will be subject to a $500 reduction.

Mental Health Services

Mental Health Services include those received on an inpatient basis in a Hospital or Alternate Facility, and those received on an outpatient basis in a provider’s office or at an Alternate Facility.

Benefits include the following services provided on either an outpatient or inpatient basis:

■ diagnostic evaluations and assessment;

■ treatment planning;

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■ referral services;

■ medication management;

■ individual, family, therapeutic group and provider-based case management services; and

■ crisis intervention.

Benefits include the following services provided on an inpatient basis:

■ Partial Hospitalization/Day Treatment; and

■ services at a Residential Treatment Facility.

Benefits include the following services on an outpatient basis:

■ Intensive Outpatient Treatment.

The Mental Health/Substance-Related and Addictive Disorder Services Administrator determines coverage for the inpatient treatment. If an Inpatient Stay is required, it is covered on a Semi-private Room basis.

You are encouraged to contact the Mental Health/ Substance-Related and Addictive Disorder Services Administrator for referrals to providers and coordination of care.

Special Mental Health Programs and Services Special programs and services that are contracted under the Mental Health/Substance-Related and Addictive Disorder Services Administrator may become available to you as 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 Plan. Any decision to participate in such program or service is at the discretion of the Covered Person and is not mandatory.

Please remember for non-Network inpatient Benefits (including an admission for Partial Hospitalization/Day Treatment and services at a Residential Treatment Facility) for a scheduled admission you must obtain prior authorization from the Mental Health/Substance-Related and Addictive Disorders Administrator in advance of any treatment, and for a non-scheduled admission (including Emergency admissions), you must provide notification as soon as is reasonably possible after admission.

Please call the mental health services phone number that appears on your ID card. Without authorization, non-Network inpatient Benefits will be subject to a $500 reduction.

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Neurobiological Disorders - Autism Spectrum Disorder Services

The Plan pays Benefits for psychiatric services for Autism Spectrum Disorder (otherwise known as neurodevelopmental 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.

These Benefits describe only the psychiatric component of treatment for Autism Spectrum Disorder. Medical treatment of Autism Spectrum Disorder is a Covered Health Service for which Benefits are available as described under the Enhanced Autism Spectrum Disorder benefit below.

Benefits include the following services provided on either an outpatient or inpatient basis:

■ Diagnostic evaluations and assessment.

■ Treatment planning.

■ Treatment and/or procedures.

■ Referral services.

■ Medication management.

■ Individual, family, therapeutic group and provider-based case management services.

■ Crisis intervention.

■ Partial Hospitalization/Day Treatment.

■ Services at a Residential Treatment Facility.


Enhanced Autism Spectrum Disorder Covered Health Services include enhanced Autism Spectrum Disorder services that are focused on educational/behavioral intervention that are habilitative in nature and that are backed by credible research demonstrating that the services or supplies have a measurable and beneficial effect on health outcomes. Benefits are provided for intensive behavioral therapies (educational/behavioral services that are focused on primarily building skills and capabilities in communication, social interaction and learning such as Applied Behavioral Analysis (ABA)).

The Mental Health/ Substance-Related and Addictive Disorder Services Administrator determines coverage for all levels of care. If an Inpatient Stay is required, it is covered on a Semi-private Room basis.

You are encouraged to contact the Mental Health/ Substance-Related and Addictive Disorder Services Administrator for referrals to providers and coordination of care.

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Please remember for non-Network inpatient Benefits (including an admission for Partial Hospitalization/Day Treatment and services at a Residential Treatment Facility) for a scheduled admission you must obtain prior authorization from the Mental Health/Substance-Related and Addictive Disorder Services Administrator in advance of any treatment, and for a non-scheduled admission (including Emergency admissions), you must provide notification as soon as is reasonably possible after admission.


Nutritional Counseling

The Plan will pay for Covered Health Services for medical education services provided by an appropriately licensed or healthcare professional when:

■ education is required for a disease in which patient self-management is an important component of treatment; and

■ there exists a knowledge deficit regarding the disease which requires the intervention of a trained health professional.

Some examples of such medical conditions include:

■ coronary artery disease;

■ congestive heart failure;

■ severe obstructive airway disease;

■ gout (a form of arthritis);

■ renal failure;

■ phenylketonuria (a genetic disorder diagnosed at infancy); and

■ hyperlipidemia (excess of fatty substances in the blood).

Benefits are limited to three nutritional counseling visits per Plan year, regardless of diagnosis. An additional three visits per Covered Person per Plan year will be covered with applicable diagnosis based on medical necessity, for a total maximum of six visits per Covered Person per year.

Note: charges in connection with obesity counseling are considered to be preventive services and are covered at 100% with no limits when rendered by a Network provider. These services are not covered when rendered by a non-Network provider. (See Preventive Care section below).

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Obesity Surgery

The Plan covers surgical treatment of morbid obesity provided by or under the direction of a Physician when all of the following are true:

■ you have a minimum Body Mass Index (BMI) greater than or equal to 40 or a BMI greater than or equal to 35 with at least one co-morbid diagnosis;

■ you have documented history of weight loss attempts through diet and exercise programs; if no history is provided, you have engaged in a Physician-approved diet and exercise program for six months prior to surgery;

■ you are at least 18 years of age;

■ you have undergone pre- and post-surgery psychological counseling regarding lifestyle changes; and

■ if you are a smoker, you have discontinued use of all tobacco products 12 weeks prior to surgery.

In addition to meeting the above criteria, the Plan covers the surgery only when performed at a Bariatric Resource Services (BRS) Designated Facility by a Network surgeon even if there are no BRS Designated Facilities near you.

Benefits are limited to one morbid obesity surgical procedure per Covered Person’s lifetime, including related outpatient services, within a two-year period that starts with the date of the first surgical procedure to treat morbid obesity, unless a multistage procedure is planned.

You will have access to a certain Network of Designated Facilities and Physicians participating in the Bariatric Resource Services (BRS) program, as defined in Section 15 Glossary, for obesity surgery services.

For obesity surgery services to be considered Covered Health Services under the BRS program, you must contact Bariatric Resource Services and speak with a nurse consultant prior to receiving services. You can contact Bariatric Resource Services by calling toll-free at 888-936-7246. If Bariatric Resource Services is not notified, then no benefits will be covered.

Note: The services described under Travel and Lodging are Covered Health Services only in connection with obesity-related services received at a Designated Facility.

Ostomy Supplies

Benefits for ostomy supplies are limited to:

■ pouches, face plates and belts;

■ irrigation sleeves, bags and ostomy irrigation catheters; and

■ skin barriers.

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Physician Fees for Surgical and Medical Services

The Plan pays Physician fees for surgical procedures and other medical care received from a Physician in a Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility, Alternate Facility, or for Physician house calls.

Physician's Office Services

Benefits are paid by the Plan for Covered Health Services received in a Primary or Specialist Physician's office for the evaluation and treatment of a Sickness or Injury provided by a general pediatrician, internist, family practitioner or general practitioner. Benefits under this section include (non-preventive) hearing exams when needed as a result of an Injury or Sickness.

Benefits for preventive services are described under Preventive Care in this section.

Please remember for Non-Network Benefits you must obtain prior authorization for Genetic Testing – BRCA. If authorization is not obtained as required, Benefits will be subject to a $500 reduction.

Please Note: Your Physician does not have a copy of your SPD, and is not responsible for knowing or communicating your Benefits.

Pregnancy - Maternity Services

Benefits for Pregnancy will be paid at the same level as Benefits for any other condition, Sickness or Injury. This includes all maternity-related medical services for prenatal care, delivery and postpartum care and any related complications, as noted below:

■ Physician services (including the services of a licensed midwife) for prenatal, delivery, and postpartum services and delivery are covered as noted in the Summary of Benefits in Section 5 – Plan Highlights. Note: The initial office visit is not included in prenatal services.

■ Hospital services provided to you and your newborn child. Your newborn child is covered for services required to treat Injury or Sickness. This includes the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities as well as routine well-baby care.

The Plan will pay Benefits for an Inpatient Stay of at least:

■ 48 hours for the mother and newborn child following a vaginal delivery; or

■ 96 hours for the mother and newborn child following a cesarean section delivery.

These are federally mandated requirements under the Newborns' and Mothers' Health Protection Act of 1996 which apply to this Plan. The Hospital or other provider is not required to get authorization for the time periods stated above. Authorizations are required

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for longer lengths of stay. If the mother agrees, the attending Physician may discharge the mother and/or the newborn child earlier than these minimum timeframes.

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.

While some services provided to you and your newborn are subject to the Coinsurance and Deductible, some are not. Please refer to the Summary of Benefits found in Section 5 – Plan Highlights.

Please remember for Non-Network Benefits, you must obtain prior authorization from Personal Health Support as soon as reasonably possible if the Inpatient Stay for the mother and/or the newborn will be longer than the timeframes indicated above. If authorization from Personal Health Support is not obtained, Benefits for the extended stay will be subject to a $500 reduction.

Preventive Care

The Plan pays for Preventive care services provided on an outpatient basis at a Physician's office, an Alternate Facility or a Hospital that encompasses 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 as required under applicable law. This Plan will cover any evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Task Force (USPSTF).

Medical screenings are considered preventive when they are conducted in the absence of Sickness for the purpose of early detection. Screenings are considered diagnostic when evidence of Sickness is already present.

Guidelines for preventive care Covered Health Services (covered at 100% when provided by a Network provider) include, but are not limited to, the services listed on the following pages.

Men Women

Adult Immunizations Diphtheria, Tetanus, Pertussis booster (every 10 years) one dose of Tdap should be substituted for a single dose of Td to cover whooping cough resurgence.

Diphtheria, Tetanus, Pertussis booster (every 10 years) as for men.

Flu: annually (unless limitations are imposed).

Flu: annually (unless limitations are imposed).

Hepatitis A & B series for those at high risk.

Hepatitis A & B series for those at high risk.

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Men Women

Herpes Zoster (shingles) 1 dose for those >60 years of age.

Herpes Zoster (shingles) 1 dose for those >60 years of age.

Human Papillomavirus (HPV) vaccine for males as recommended by physician (series of 3 doses over 6 months between ages 9 to 12).

Catch-up vaccine for ages 13 to 26 for those who did not receive it at a younger age.

Human Papillomavirus (HPV) vaccine for females as recommended by physician (series of 3 doses over 6 months between ages 9 to 12).


H1N1 Flu: as recommended by PCP and/or CDC.

H1N1 Flu: as recommended by PCP and/or CDC.

Meningitis if high risk (adults without a spleen and all first year college students living in dormitories) (1 dose) (adults without a spleen and all first year college students living in dormitories).

Meningitis if high risk (adults without a spleen or all first year college students living in dormitories) (1 dose) as in men.

Pneumonia vaccine if > age 65 & those at high risk (1 dose).

Pneumonia vaccine if > age 65 & those at high risk (1 dose).

Varicella (chicken pox) for those at risk and adults born after 1980 unless you had chicken pox or shingles or 2 prior doses of vaccine (1 dose) and adults born after 1980 unless had varicella or zoster documented or prior 2 doses of vaccine.

Varicella (chicken pox) for those at risk and all adults born after 1980 unless you have had chicken pox or shingles or 2 prior doses of vaccine (1 dose) as for men.

Blood Pressure Regular screenings at least every 2 years or as ordered by your physician.

Regular screenings at least every 2 years or as ordered by your physician.

Breast Cancer One mammogram per plan year recommended beginning at age 40 or earlier if medically necessary.

One baseline mammogram recommended for those

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Men Women

between age 35 and 40.

Clinical breast exam annually.

Cervical cancer One Pap smear per plan year recommended beginning at age 18 or as ordered by your physician.

Cholesterol Every 5 years beginning at age 40; begin at age 20 if other risk factors for CAD are present.

Every 5 years beginning at age 40; begin at age 20 if other risk factors for CAD are present.

Colorectal cancer Fecal occult blood annually & sigmoidoscopy every 5 years beginning at age 50.

OR colonoscopy every 10 years; or earlier as a result of family history.

OR double contrast barium enema every 5 years.

Fecal occult blood annually & sigmoidoscopy every 5 years beginning at age 50.

OR colonoscopy every 10 years, or earlier as a result of family history.

OR double contrast barium enema every 5 years.

Diabetes Fasting blood sugar at age 40 for those with risk factors Anyone over 40 with hypertension or hyperlipidemia should be screened.

Fasting blood sugar at age 40 for those with risk factors as with men.

Obesity Counseling Unlimited visits as needed. Unlimited visits as needed.

Osteoporosis Bi-annual (every 2 years) bone density screening for women age 65 & over.

One baseline for those with one or more risk factors.

Prostate cancer Annual digital rectal exam and PSA beginning at age 45 or earlier as a result of family history.

Screening for Abdominal Aortic Aneurysm

One-time screening by ultrasonography for men over age 65 with a history of tobacco use.

Counseling and/or screening for alcohol abuse

Counseling and/or screening for men aged 18 years or older for alcohol misuse and provide persons engaged in risky or

Counseling and/or screening for women aged 18 years or older for alcohol misuse and provide persons engaged in

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Men Women

hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse.

risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse.

Counseling and/or screening for tobacco use

Counseling and/or screening for men regarding tobacco use and providing tobacco cessation interventions for those who use tobacco products.

Counseling and/or screening for women regarding tobacco use and providing tobacco cessation interventions for those who use tobacco products, including augmented, pregnancy-tailored counseling for those who smoke.

Women’s Preventive Care Services

Includes:

- Annual counseling for interpersonal and domestic violence,

- Annual screening and counseling for sexually transmitted diseases,

- Annual screening and counseling for Human Immune Deficiency (HIV),

- Annual screenings for High Risk Human Papillomavirus (HPV) DNA testing for women age 30 and older, and

- Screening for gestational diabetes.

- Breast feeding – Includes:

- Breast feeding support,

- Lactation counseling, and

- Breast feeding supplies, including breast pumps (1 breast pump per birth).

Note: Benefits are only available if the breast pumps are obtained from a DME provider or Physician. If more

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Men Women

than one breast pump can meet your needs, Benefits are available only for the most cost effective pump. The Claims Administrator will determine which pump is the most cost effective; whether the pump should be purchased or rented; the duration of the rental; and the timing of the acquisition.

- Contraception. – Includes: FDA approved contraception methods, sterilization procedures and patient counseling, as noted below:

- Contraceptive counseling,

- Contraceptive devices prescribed by a physician,

- Office visit for the injection of injectable contraceptives,

- Voluntary sterilization for women, and

- Related outpatient services such as consultations, exams and procedures. Note: Other/oral contraceptive drugs (other and abortifacient drugs) may be covered under your prescription drug plan.

- Well-woman visits – Includes annual office visits to obtain the recommended preventive services that are age and developmentally appropriate, including

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Men Women

preconception and routine prenatal care services.

Note: Initial visit to confirm pregnancy, along with the delivery, post-natal care, laboratory tests and care required due to complications of pregnancy are not considered routine maternity care, thus, they are subject to Coinsurance.

Children (0-19 Years)

Anemia Within 7 days of birth.

Cervical cancer Pap Smear & routine pelvic exam: annual beginning at age 18 or as ordered by your physician. First Pap smear of the plan year is considered preventive. Subsequent pap smears are considered diagnostic.

Immunizations Diphtheria, tetanus, pertussis (DPT) at 2, 4, 6 months; between 15-18 months, 4-6 years of age and adolescents age 11-12.

Tetanus-Diphtheria (DT): booster between 11-12 years and then every 10 years.

Polio: 2, 4 months; 6-18 months & 4-6 years of age (4 doses).

Measles, Mumps, Rubella (MMR): 12-15 months & 4-6 years of age (2 doses); 1 dose between 11-12 years if the second dose was never received; 1 dose at age 19 & older if vaccine unreliable.

Hepatitis B: 1-18 months (series of 3 or 4 doses).

Hepatitis A for selected populations: 2-18 years of age (2 doses separated by at least 6 months between ages 2-17.

Varicella (chicken pox): 12-18 months and age 4-6 and age 4-6.

Pneumococcal: 2, 4, 6 months, 12-18 months and for certain high risk groups and for certain high risk groups again at 4-6 years.

Haemophilus influenza type b (HIB): 2, 4 & 6 months & between 12-15 months (4 doses).

Flu: annually for children > 6 months to 9 years of age; after the first dose, a booster one month later.

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Children (0-19 Years)

H1N1 Flu: as recommended by PCP and/or CDC for those > age 10. Two (2) doses for children 6 months through age 9 (doses at least 21 days apart).

Meningitis: Age 11-12 years and if high risk (those without a spleen or college freshman living in dormitories) administer to all aged 11-12 yrs. if not previously vaccinated.

Human Papillomavirus (HPV) vaccine for females as recommended by physician (series of 3 doses over 6 months between ages 9 to 12).


Rotavirus (RV): at 2, 4,and 6 months of age (series of 3 doses).

Lead levels One at 12 months of age and 1 at 24 months of age (2 tests).

Obesity counseling Unlimited visits as needed.

Phenylketonuria (PKU)

Within 7 days of birth.

Thyroid, congenital disorders or neural tube defects

Within 7 days of birth.

Well-child care

Newborn well care inpatient visits (postnatal);

7 visits in the first 12 months; 3 visits in the second 12 months; 3 visits in the third 12 months; and

Annual visits from 36 months to age 18.

For questions about your preventive care Benefits under this Plan call the number on the back of your ID card.

Prosthetic Devices

Benefits are paid by the Plan for prosthetic devices and appliances that replace a limb or body part, or help an impaired limb or body part work. Examples include, but are not limited to:

■ artificial limbs;

■ artificial eyes; and

■ breast prosthesis following mastectomy as required by the Women's Health and Cancer Rights Act of 1998, including mastectomy bras and lymphedema stockings for the arm.

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If more than one prosthetic device can meet your functional needs, Benefits are available only for the most Cost-Effective prosthetic device. The device must be ordered or provided either by a Physician, or under a Physician's direction.

Benefits are provided for the replacement of a type of prosthetic device once every three Plan years. At UnitedHealthcare's discretion, prosthetic devices may be covered for damage beyond repair with normal wear and tear, when repair costs are less than the cost of replacement, when replacement is due to growth, or when a change in the Covered Person's medical condition occurs sooner than the three year timeframe. Replacement of artificial limbs or any part of such devices may be covered when the condition of the device or part requires repairs that cost more than the cost of a replacement device or part.

Note: Prosthetic devices are different from DME - see Durable Medical Equipment (DME) in this section.

Reconstructive Procedures

Reconstructive Procedures are services performed when the primary purpose of the procedure is either to treat a medical condition or to improve or restore physiologic function for an organ or body part. Reconstructive procedures include surgery or other procedures which are associated with an Injury, Sickness or Congenital Anomaly. The primary result of the procedure is not a changed or improved physical appearance.

Improving or restoring physiologic function means that the organ or body part is made to work better. An example of a Reconstructive Procedure is surgery on the inside of the nose so that a person's breathing can be improved or restored.

Benefits for Reconstructive Procedures include breast reconstruction following a mastectomy and reconstruction of the non-affected breast to achieve symmetry. Replacement of an existing breast implant is covered by the plan if the initial breast implant followed mastectomy. Other services required by the Women's Health and Cancer Rights Act of 1998, including breast prostheses and treatment of complications, are provided in the same manner and at the same level as those for any other Covered Health Service. You can contact UnitedHealthcare at the telephone number on your ID card for more information about Benefits for mastectomy-related services.

There may be times when the primary purpose of a procedure is to make a body part work better. However, in other situations, the purpose of the same procedure is to improve the appearance of a body part. Cosmetic procedures are excluded from coverage. Procedures that correct an anatomical Congenital Anomaly without improving or restoring physiologic function are considered Cosmetic Procedures. A good example is upper eyelid surgery. At times, this procedure will be done to improve vision, which is considered a Reconstructive Procedure. In other cases, improvement in appearance is the primary intended purpose, which is considered a Cosmetic Procedure. This plan does not provide Benefits for Cosmetic Procedures, as defined in Section 15, Glossary.

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The fact that a Covered Person may suffer psychological consequences or socially avoidant behavior as a result of an Injury, Sickness or Congenital Anomaly does not classify surgery (or other procedures done to relieve such consequences or behavior) as a reconstructive procedure.

Please remember that you must obtain prior authorization from Personal Health Support five business days before undergoing a Reconstructive Procedure. When you obtain authorization, Personal Health Support can determine whether the service is considered reconstructive or cosmetic. Cosmetic Procedures are always excluded from coverage. If authorization is not obtained as required, Benefits will be subject to a $500 reduction.

Rehabilitation Services - Outpatient Therapy

The plan provides short-term outpatient rehabilitation services for the following types of therapy:

■ physical therapy;

■ occupational therapy;

■ speech therapy;

■ pulmonary rehabilitation; and

■ cardiac rehabilitation.

For all rehabilitation services, a licensed therapy Provider, under the direction of a Physician (when required by state law), must perform the services as part of a treatment plan.

For physical and occupational therapy services, treatment must also be expected to significantly improve, develop, or restore physical functions lost or impaired because of an acute illness, injury or surgical procedure; or re-teach skills to improve independence in the activities of daily living. The plan will also cover physical and occupational therapy for developmental delays, including Autism Spectrum Disorders.

For speech therapy services, treatment must also be expected to restore the loss of speech function or correct a speech impairment resulting from disease or injury; or to treat delays in the development of speech function that are the result of a gross anatomical defect present at birth (for example, a cleft palate or a cleft lip). The plan will pay Benefits for speech therapy only when the speech impediment or dysfunction results from Injury, Sickness, stroke, cancer, developmental delays (including Autism Spectrum Disorders) or a Congenital Anomaly, or is needed following the placement of a cochlear implant.

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.

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Benefits are limited to:

■ 60 visits per Plan Year for physical and occupational therapy combined; and

■ 40 visits per Plan Year for speech therapy.

These visit limits apply to Network Benefits and Non-Network Benefits combined.

Scopic Procedures - Outpatient Diagnostic and Therapeutic

The HSP pays for diagnostic and therapeutic scopic procedures and related services received on an outpatient basis at a Hospital or Alternate Facility or in a Physician's office.

Diagnostic scopic procedures are those for visualization, biopsy and polyp removal. Examples of diagnostic scopic procedures include colonoscopy, sigmoidoscopy, and endoscopy.

Please note that Benefits under this section do not include surgical scopic procedures, which are for the purpose of performing surgery. Benefits for surgical scopic procedures are described under Surgery - Outpatient. Examples of surgical scopic procedures include arthroscopy, laparoscopy, bronchoscopy, hysteroscopy.

Skilled Nursing Facility/Inpatient Rehabilitation Facility Services

Facility services for an Inpatient Stay in a Skilled Nursing Facility or Inpatient Rehabilitation Facility are covered by the Plan. Benefits include:

■ non-Physician services and supplies received during the Inpatient Stay; and

■ room and board in a Semi-private Room (a room with two or more beds).

Benefits are available when skilled nursing and/or Inpatient Rehabilitation Facility services are needed on a daily basis. Benefits are also available in a Skilled Nursing Facility or Inpatient Rehabilitation Facility for treatment of a Sickness or Injury that would have otherwise required an Inpatient Stay in a Hospital.

UnitedHealthcare will determine if Benefits are available by reviewing both the skilled nature of the service and the need for Physician-directed medical management. A service will not be determined to be "skilled" simply because there is not an available caregiver.

Benefits are available only 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; and

■ you will receive skilled care services that are not primarily Custodial Care.

Skilled care is skilled nursing, skilled teaching, and skilled rehabilitation services when:

■ it is 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;

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■ it is ordered by a Physician;

■ it is not delivered for the purpose of assisting with activities of daily living, including but not limited to dressing, feeding, bathing or transferring from a bed to a chair; and

■ it requires clinical training in order to be delivered safely and effectively.

You are expected to improve to a predictable level of recovery.

Note: The plan does not pay Benefits for Custodial Care or Domiciliary Care, even if ordered by a Physician, as defined in Section 15, Glossary.

Any combination of Network Benefits and Non-Network Benefits is limited to 120 days per Plan Year.

Please remember for Non-Network Benefits for a:

■ scheduled admissions, you must obtain prior authorization five business days before admission;

■ non-scheduled admission (including Emergency admissions), you must provide notification within two business days after admission, or on the same day of admission if reasonably possible.

If prior authorization is not obtained as required, or notification is not provided, Benefits will be subject to a $500 reduction.

Spinal Treatment and Chiropractic Services

The HSP pays Benefits for Spinal Treatment when provided by a network or non-network Spinal Treatment specialist in the specialist's office. Covered Health Services include chiropractic and osteopathic manipulative therapy.

The plan gives UnitedHealthcare the right to deny Benefits if treatment ceases to be therapeutic and is instead administered to maintain a level of functioning or to prevent a medical problem from occurring or recurring.

Benefits include diagnosis and related services. The HSP limits any combination of network and non-network Benefits for Spinal Treatment to one visit per day up to 15 visits per Plan Year.

Substance-Related and Addictive Disorder Services

Substance-Related and Addictive 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.

Benefits include the following services provided on either an inpatient or outpatient basis:

■ diagnostic evaluations and assessment;

■ treatment planning;

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■ referral services;

■ medication management;

■ individual, family, therapeutic group and provider-based case management;

■ crisis intervention; and

■ detoxification (sub-acute/non-medical).

Benefits include the following services provided on an inpatient basis:

■ Partial Hospitalization/Day Treatment; and

■ services at a Residential Treatment Facility.

Benefits include the following services provided on an outpatient basis:


The Mental Health/Substance-Related and Addictive Disorder Services Administrator determines coverage for the inpatient treatment. If an Inpatient Stay is required, it is covered on a Semi-private Room basis.

You are encouraged to contact the Mental Health/Substance-Related and Addictive Disorder Services Administrator for referrals to providers and coordination of care.

Special Substance Use Disorder Programs and Services Special programs and services that are contracted under the Mental Health/Substance-Related and Addictive Disorder Services Administrator may become available to you as part of your Substance-Related and Addictive Disorder Services benefit. The Substance-Related and Addictive 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-Related and Addictive Disorder Services which may not otherwise be covered under this Plan. Any decision to participate in such program or service is at the discretion of the Covered Person and is not mandatory.

Please remember for non-Network inpatient Benefits (including an admission for Partial Hospitalization/Day Treatment and services at a Residential Treatment Facility) for a scheduled admission you must obtain prior authorization from the Mental Health/Substance-Related and Addictive Disorder Services Administrator in advance of any treatment, and for a non-scheduled admission (including Emergency admissions), you must provide notification as soon as is reasonably possible after admission.


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Surgery Outpatient

The HSP pays for surgery and related services received on an outpatient basis at a Hospital or Alternate Facility.

Benefits under this section include:

■ the facility charge and the charge for supplies and equipment; and

■ certain surgical scopic procedures (examples of surgical scopic procedures include arthroscopy, laparoscopy, bronchoscopy, hysteroscopy).

Benefits for other Physician services are described in this section under Physician Fees for Surgical and Medical Services.

Please remember for Non-Network Benefits for cardiac catheterization1, pacemaker insertion1, implantable cardioverter defibrillators1, diagnostic catheterization, electrophysiology implant and sleep apnea surgeries you must obtain prior authorization five business days before scheduled services are received or, for non-scheduled services, within two business days or as soon as is reasonably possible. If authorization is not obtained as required, Benefits will be subject to a $500 reduction.

Temporomandibular Joint Dysfunction (TMJ)

The HSP covers diagnostic and surgical treatment of conditions affecting the temporomandibular joint when provided by or under the direction of a Physician, as longs as the services are not considered dental in nature. Coverage includes necessary treatment required as a result of accident, trauma, a Congenital Anomaly, developmental defect, or pathology.

Therapeutic Treatments - Outpatient

The HSP pays Benefits for therapeutic treatments received on an outpatient basis at a Hospital or Alternate Facility, including but not limited to 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:

■ education is required for a disease in which patient self-management is an important component of treatment; and

■ there exists a knowledge deficit regarding the disease which requires the intervention of a trained health professional.

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Please remember for Non-Network Benefits for dialysis, intensity modulated radiation therapy and MR-guided focused ultrasounds, you must obtain prior authorization five business days before scheduled services are received or, for non-scheduled services, within two business days or as soon as is reasonably possible. If you fail to obtain prior authorization as required, Benefits will be subject to a $500 reduction.

Transplantation Services

Inpatient facility services (including evaluation for transplant, organ procurement and donor searches) for transplantation procedures must be ordered by a Network provider and received at a Designated Facility. Benefits are available to the donor and the recipient when the recipient is covered under this plan. The transplant must meet the definition of a Covered Health Service and cannot be Experimental or Investigational, or Unproven.

Examples of transplants for which Benefits are available include, but are not limited to:

■ heart;

■ heart/lung;

■ lung;

■ kidney;

■ kidney/pancreas;

■ liver;

■ liver/kidney;

■ liver/intestinal;

■ pancreas;

■ intestinal; and

■ bone marrow (either from you or from a compatible donor) and peripheral stem cell transplants, with or without high dose chemotherapy. Not all bone marrow transplants meet the definition of a Covered Health Service – please see below.

Benefits are also available for cornea transplants that are provided by a Provider at a Hospital. You are not required to notify United Resource Networks or Personal Health Support of a cornea transplant nor is the cornea transplant required to be performed at a Designated Facility.

Please remember that all transplants, with the exception of cornea transplants, must be performed at a Designated Facility by a Network surgeon.

Donor costs that are directly related to organ removal are Covered Health Services for which Benefits are payable under the organ recipients coverage under the plan. These services include:

■ obtaining donated organs (including removal from a cadaver);

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■ donor medical and surgical expenses related to obtaining the organ that are integral to the harvesting or directly related to the donation and limited to treatment occurring during the same stay as the harvesting; and

■ transportation of the organ from donor to the recipient.

The HSP has specific guidelines regarding Benefits for transplant services. Contact United Resource Networks at (888) 936-7246 or Personal Health Support at the telephone number on your ID card for information about these guidelines.

Note: The services described under Travel and Lodging are Covered Health Services only in connection with transplant services received at a Designated Facility.

Please remember that you must contact United Resource Networks or Personal Health Support as soon as the possibility of a transplant arises (and before the time a pre-transplantation evaluation is performed at a transplant center). If United Resource Networks or Personal Health Support is not notified, and if as a result, the services are not performed at a Designated Facility, no benefits will be paid and you will be responsible for paying all charges.

Travel and Lodging

United Resource Networks or Personal Health Support will assist the patient and family with travel and lodging arrangements related to:

■ Congenital Heart Disease (CHD);

■ transplantation services;

■ obesity surgery services; and

■ cancer-related treatments.

For travel and lodging services to be covered, the patient must be receiving services at a Designated Facility through United Resource Networks.

The HSP covers expenses for travel and lodging for the patient, provided he or she is not covered by Medicare, and a companion as follows:

■ transportation of the patient and one companion who is traveling on the same day(s) to and/or from the site of the cancer-related treatment, the obesity surgery service, the CHD service, or the transplant for the purposes of an evaluation, the procedure or necessary post-discharge follow-up;

■ Eligible Expenses for lodging for the patient (while not a Hospital inpatient) and one companion. Benefits are paid at a per diem (per day) rate of up to $50 per day for the patient or up to $100 per day for the patient plus one companion; or

■ if the patient is an enrolled Dependent minor child, the transportation expenses of two companions will be covered and lodging expenses will be reimbursed at a per diem rate up to $100 per day.

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Travel and lodging expenses are only available if the recipient lives more than 75 miles from the Designated Facility (for CRS, obesity surgery and transplantation) or the CHD facility. UnitedHealthcare must receive valid receipts for such charges before you will be reimbursed. Examples of travel expenses may include:

■ airfare at coach rate;

■ taxi or ground transportation; or

■ mileage reimbursement at the IRS rate for the most direct route between the patient's home and the Designated Facility.

There is a combined overall lifetime maximum of $10,000 per Covered Person for all transportation and lodging expenses incurred by the patient and companion(s) and reimbursed under this plan in connection with all transplant procedures, CHD treatments, obesity surgery services or cancer-related services.

Support In The Event Of Serious Illness If you or a covered family member has cancer or needs an organ or bone marrow transplant, UnitedHealthcare can put you in touch with quality treatment centers around the country.

Urgent Care Center Services

The HSP provides Benefits for services, including professional services, received at an Urgent Care Center, as defined in Section 15, Glossary. When Urgent Care services are provided in a Physician's office, the plan pays Benefits as described under Physician's Office Services earlier in this section.

Virtual Visits

Virtual visits for Covered Health Services that include the diagnosis and treatment of low acuity medical conditions for Covered Persons, through the use of interactive audio and video telecommunication and transmissions, and audio-visual communication technology. Virtual visits provide communication of medical information in real-time between the patient and a distant Physician or health care specialist, through use of interactive audio and video communications equipment outside of a medical facility (for example, from home or from work).

Benefits are available only when services are delivered through a Designated Virtual Network Provider. You can find a Designated Virtual Network Provider by going to www.myuhc.com or by calling the telephone number on your ID card.

Please Note: Not all medical conditions can be appropriately treated through virtual visits. The Designated Virtual Network Provider will identify any condition for which treatment by in-person Physician contact is necessary.

Benefits under this section do not include email, fax and standard telephone calls, or for telehealth/telemedicine visits that occur within medical facilities (CMS defined originating facilities).

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72 SECTION 7 – RESOURCES TO HELP YOU STAY HEALTHY

SECTION 7 - RESOURCES TO HELP YOU STAY HEALTHY

What This Section Includes: Health and well-being resources available to you, including: ■ Consumer Solutions and Self-Service Tools; and

■ Disease and Condition Management Services.

CVS believes in giving you the tools you need to be an educated health care consumer. To that end, CVS has made available several convenient educational and support services, accessible by phone and the Internet, which can help you to:

■ take care of yourself and your family members;

■ manage a chronic health condition; and

■ navigate the complexities of the health care system.

Note: Information obtained through the services identified in this section is based on current medical literature and on Physician review. It is not intended to replace the advice of a doctor. The information is intended to help you make better health care decisions and take a greater responsibility for your own health. UnitedHealthcare and CVS are not responsible for the results of your decisions from the use of the information, including, but not limited to, your choosing to seek or not to seek professional medical care, or your choosing or not choosing specific treatment based on the text.

Consumer Solutions and Self-Service Tools

NurseLineSM

NurseLineSM is a telephone service that puts you in immediate contact with an experienced registered nurse any time, 24 hours a day, seven days a week. Nurses can provide health information for routine or urgent health concerns. When you call, a registered nurse may refer you to any additional resources that Circle Graphics, Inc. has available to help you improve your health and well-being or manage a chronic condition. Call any time when you want to learn more about:

■ A recent diagnosis.

■ A minor Sickness or Injury.

■ Men's, women's, and children's wellness.

■ How to take Prescription Drug Products safely.

■ Self-care tips and treatment options.

■ Healthy living habits.

■ Any other health related topic.

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NurseLineSM gives you another convenient way to access health information. By calling the same number, you can listen to one of the Health Information Library's over 1,100 recorded messages, with over half in Spanish.

NurseLineSM is available to you at no cost. To use this convenient service, simply call the number on the back of your ID card.

Note: If you have a medical emergency, call 911 instead of calling NurseLineSM.

Your child is running a fever and it's 1:00 AM. What do you do? Call NurseLineSM any time, 24 hours a day, seven days a week. You can count on NurseLineSM to help answer your health questions.

With NurseLineSM, you also have access to nurses online. To use this service, log onto www.myuhc.com and click "Live Nurse Chat" in the top menu bar. You'll instantly be connected with a registered nurse who can answer your general health questions any time, 24 hours a day, seven days a week. You can also request an e-mailed transcript of the conversation to use as a reference.

Note: If you have a medical emergency, call 911 instead of logging onto www.myuhc.com.

Treatment Decision Support In order to help you make informed decisions about your health care, UnitedHealthcare has a program called Treatment Decision Support. This program targets specific conditions as well as the treatments and procedures for those conditions.

This program offers:

■ access to accurate, objective and relevant health care information;

■ coaching by a nurse through decisions in your treatment and care;

■ expectations of treatment; and

■ information on high quality providers and programs.

Conditions for which this program is available include:

■ back pain;

■ knee & hip replacement;

■ prostate disease;

■ prostate cancer;

■ benign uterine conditions;

■ breast cancer;

■ coronary disease; and

■ bariatric surgery.

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Participation is completely voluntary and without extra charge. If you think you may be eligible to participate or would like additional information regarding the program, please contact the number on the back of your ID card.

UnitedHealth PremiumSM Program UnitedHealthcare designates Network Physicians and facilities as UnitedHealth Premium Program Physicians or facilities for certain medical conditions. Physicians and facilities are evaluated on two levels - quality and efficiency of care. The UnitedHealth Premium Program was designed to:

■ help you make informed decisions on where to receive care;

■ provide you with decision support resources; and

■ give you access to Physicians and facilities across areas of medicine that have met UnitedHealthcare's quality and efficiency criteria.

For details on the UnitedHealth Premium Program including how to locate a UnitedHealth Premium Physician or facility, log onto www.myuhc.com or call the toll-free number on your ID card.

UnitedHealthcare's member website, www.myuhc.com provides information at your fingertips anywhere and anytime you have access to the Internet. www.myuhc.com opens the door to a wealth of health information and convenient self-service tools to meet your needs.

With www.myuhc.com you can:

■ research a health condition and treatment options to get ready for a discussion with your Physician;

■ search for Network Providers available in your Plan through the online Provider directory;

■ use the treatment cost estimator to obtain an estimate of the costs of various procedures in your area; and

■ use the Hospital comparison tool to compare Hospitals in your area on various patient safety and quality measures.

Registering on www.myuhc.com If you have not already registered as a www.myuhc.com subscriber, simply go to www.myuhc.com and click on "Register Now." Have your UnitedHealthcare ID card handy. The enrollment process is quick and easy.

Visit www.myuhc.com and:

■ make real-time inquiries into the status and history of your claims;

■ view eligibility and Plan Benefit information, including the Annual Deductible and Out of Pocket Maximums;

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■ view and print all of your Explanation of Benefits (EOBs) online; and

■ order a new or replacement ID card or, print a temporary ID card.

Periodically, www.myuhc.com hosts live events with leading health care professionals. After viewing a presentation, you can chat online with the experts. Topics include:

■ weight control;

■ parenting;

■ heart disease;

■ relationships; and

■ depression.

For details, or to participate in a live event, log onto www.myuhc.com.

Want To Learn More About A Condition Or Treatment? Log on to www.myuhc.com and research health topics that are of interest to you. Learn about a specific condition, what the symptoms are, how it is diagnosed, how common it is, and what to ask your Physician.

Disease and Condition Management Services

Cancer Support Program UnitedHealthcare provides a program that identifies, assesses, and supports members who have cancer. The program is designed to support you. This means that you may be called by a registered nurse who is a specialist in cancer and receive free educational information through the mail. You may also call the program and speak with a nurse whenever you need to. This nurse will be a resource and advocate to advise you and to help you manage your condition. This program will work with you and your Physicians, as appropriate, to offer education on cancer, and self-care strategies and support in choosing treatment options.

Participation is completely voluntary and without extra charge. If you think you may be eligible to participate or would like additional information regarding the program, please call the number on the back of your ID card or call the program directly at (866) 936-6002.

For information regarding specific Benefits for cancer treatment within the Plan, see Section 6, Additional Coverage Details under the heading Cancer Resource Services (CRS).

Real Appeal Program

UnitedHealthcare provides the Real Appeal program, which represents a practical solution for weight related conditions, with the goal of helping people at risk from obesity-related diseases and those who want to maintain a healthy lifestyle. This program is open to Employees, spouses and dependent children (at least 18 years of age) who have a body mass index (BMI) of 23 of greater. This intensive, multi-component behavioral intervention provides a 52-week virtual approach that includes one-on-one coaching and online group

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participation with supporting video content, delivered by a live virtual coach. The experience will be personalized for each individual through an introductory call.

This program will be individualized and may include, but is not limited to, the following:

■ Online support and self-help tools: Personal one-on-one coaching, group support sessions, including integrated telephonic support, and mobile applications.

■ Education and training materials focused on goal setting, problem-solving skills, barriers and strategies to maintain changes.

■ Behavioral change guidance and counseling by a specially trained health coach for clinical weight loss.

Participation is completely voluntary and without any additional charge or cost share. There are no Copays, Coinsurance, or Deductibles that need to be met when services are received as part of the Real Appeal program. If you would like to participate, or if you would like any additional information regarding the program, please call Real Appeal at 1-844-344-REAL (1-844-344-7325). TTY users can dial 711 or visit www.realappeal.com.

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77 SECTION 8 - EXCLUSIONS

SECTION 8 - EXCLUSIONS: WHAT THE MEDICAL PLAN WILL NOT COVER

What This Section Includes: ■ Services, supplies and treatments that are not Covered Health Services, except as may

be specifically provided for in Section 6, Additional Coverage Details.

The HSP does not pay Benefits for the following services, treatments or supplies even if they are recommended or prescribed by a Provider or are the only available treatment for your condition.

When Benefits are limited within any of the Covered Health Services categories described in Section 6, Additional Coverage Details, those limits are stated in the corresponding Covered Health Service category in Section 5, Medical Plan Highlights. 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 Section 5, Medical Plan Highlights. Please review all limits carefully, as the plan will not pay Benefits for any of the services, treatments, items or supplies that exceed these benefit limits.

Please note that in listing services or examples, when the SPD says "this includes," or "including but not limiting to", it is not UnitedHealthcare's intent to limit the description to that specific list. When the plan does intend to limit a list of services or examples, the SPD specifically states that the list "is limited to."

Alternative Treatments

1. acupressure;

2. acupuncture;

3. aromatherapy;

4. hypnotism;

5. massage therapy;

6. rolfing (holistic tissue massage); and

7. other forms of alternative treatment as defined by the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health, including holistic or homeopathic care.

Comfort and Convenience

Supplies, equipment and similar incidentals for personal comfort. Examples include:

1. television;

2. telephone;

3. air conditioners;

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4. beauty/barber service;

5. guest service;

6. air purifiers and filters;

7. batteries and battery chargers;

8. dehumidifiers and humidifiers;

9. ergonomically correct chairs;

10. non-hospital beds and comfort beds;

11. devices and computers to assist in communication and speech; and

12. home remodeling to accommodate a health need (including, but not limited to, ramps, swimming pools, elevators, handrails, and stair glides).

Dental

1. dental care, except as identified under Dental Services - Accident Only in Section 6, Additional Coverage Details.

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 Plan, as identified in Section 6, Additional Coverage Details;

2. services for the evaluation and treatment of temporomandibular joint syndrome (TMJ), when the services are considered dental in nature, including oral appliances;

3. preventive dental care;

4. diagnosis or treatment of the teeth or gums, such as:

- extractions (except for impacted wisdom teeth, subject to the limitations described in under Dental Services – Accident Only in Section 6, Additional Coverage Details);

- restoration and replacement of teeth; - medical or surgical treatments of dental conditions; and - services to improve dental clinical outcomes;

5. dental implants and braces;

6. dental X-rays, supplies and appliances and all associated expenses, including hospitalizations and anesthesia; and

7. treatment of malpositioned or supernumerary (extra) teeth, even if part of a Congenital Anomaly such as cleft lip or cleft palate.

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Experimental, Investigational or Unproven Services

1. Drugs, devices, treatment or procedures that are considered to be either (1) Experimental or Investigational or (2) Unproven services, as defined in Section 15, Glossary, are excluded from coverage, unless the plan has agreed to cover them as defined in Section 6, Additional Coverage Details.

This exclusion applies even if Experimental, Investigational Services or Unproven Services, treatments, devices or pharmacological regimens are the only available treatment options for your condition.

This exclusion does not apply to Covered Health Services provided during a Clinical Trial for which Benefits are provided as described in Section 6, Additional Coverage Details of this booklet, under Clinical Trials.

Foot Care

1. routine foot care, except when needed for severe systemic disease. Routine foot care services that are not covered include:

- cutting or removal of corns and calluses; - nail trimming or cutting; and - debriding (removal of dead skin or underlying tissue);

2. hygienic and preventive maintenance foot care. Examples include:

- cleaning and soaking the feet; - applying skin creams in order to maintain skin tone; and other services that are

performed when there is not a localized Sickness, Injury or symptom involving the foot.

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;

3. treatment of flat feet;

4. shoe inserts, arch supports, shoes (standard or custom), lifts and wedges and shoe orthotics except when prescribed by a Physician as described under Durable Medical Equipment (DME) in Section 6, Additional Coverage Details; and

5. treatment of subluxation of the foot.


1. reversal of genital surgery or reversal of surgery to revise secondary sex characteristics;

2. sperm preservation in advance of hormone treatment or gender surgery;

3. cryopreservation of fertilized embryos;

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4. voice modification surgery; and

5. facial feminization surgery.

Medical Supplies and Appliances

1. devices used specifically as safety items or to affect performance in sports-related activities;

2. prescribed or non-prescribed medical supplies, except for ostomy bags and related supplies. Examples of supplies that are not covered include, but are not limited to:

- elastic stockings, ace bandages, diabetic strips, and syringes; and - tubings, nasal cannulas, connectors and masks that are not used in connection with

DME;

3. orthotic appliances and devices, except as described under Durable Medical Equipment in Section 6, Additional Coverage Details.

Examples of excluded orthotic appliances include but are not limited to, braces that can be obtained without a Physician’s order; and

4. deodorants, filters, lubricants, tape, appliance cleaners, adhesive, adhesive remover or other items that are not specifically identified under Ostomy Supplies in Section 6, Additional Coverage Details.

Mental Health, Neurobiological Disorders - Autism Spectrum Disorder and Substance-Related and Addictive Disorders Services

In addition to all other exclusions listed in this Section 8, Exclusions, the exclusions listed directly below apply to services described under Mental Health Services, Neurobiological Disorders - Autism Spectrum Disorder Services and/or Substance-Related and Addictive Disorders Services in Section 6, Additional Coverage Details.

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. Outside of an initial assessment, services as treatments for a primary diagnosis of conditions and problems that may be a focus of clinical attention, but are specifically noted not to be mental disorders within the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association;

3. Outside of initial assessment, services as treatments for the primary diagnoses of learning disabilities, conduct and impulse control disorders, pyromania, kleptomania, gambling disorder and paraphilic disorder;

4. Educational/behavioral services that are focused on primarily building skills and capabilities in communication, social interaction and learning;

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5. Tuition for or services that are school-based for children and adolescents required to be provided by, or paid for by, the school under the Individuals with Disabilities Education Act;

6. Outside of initial assessment, unspecified disorders for which the provider is not obligated to provide clinical rationale as defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association; and

7. Methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol), Cyclazocine, or their equivalents for drug addiction.

Nutrition and Health Education

1. nutritional or cosmetic therapy using high dose or mega quantities of vitamins, minerals or elements, and other nutrition based therapy;

2. nutritional counseling for either individuals or groups, except as identified under Diabetes Services, and except as defined under Nutritional Counseling in Section 6, Additional Coverage Details;

3. food of any kind. Foods that are not covered include:

- enteral feedings and other nutritional and electrolyte formulas, including infant formula and donor breast milk, unless they are the only source of nutrition or unless they are specifically created to treat inborn errors of metabolism such as phenylketonuria (PKU). Infant formula available over the counter is always excluded;

- foods to control weight, treat obesity (including liquid diets), lower cholesterol or control diabetes;

- oral vitamins and minerals; - meals you can order from a menu, for an additional charge, during an Inpatient Stay;

and - other dietary and electrolyte supplements;

4. health club memberships and programs, and spa treatments; and

5. health education classes unless offered by UnitedHealthcare or its affiliates, including but not limited to asthma, smoking cessation, and weight control classes.

Physical Appearance

1. Cosmetic Procedures, as defined in Section 15, Glossary, are excluded from coverage. Examples include:

- liposuction; - pharmacological regimens; - nutritional procedures or treatments; - tattoo or scar removal or revision procedures (such as salabrasion, chemosurgery and

other such skin abrasion procedures); and

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- replacement of an existing intact breast implant if the earlier breast implant was performed as a Cosmetic Procedure;

2. physical conditioning programs such as athletic training, bodybuilding, exercise, fitness, flexibility, and diversion or general motivation;

3. weight loss programs whether or not they are under medical supervision or for medical reasons, even if for morbid obesity;

4. wigs regardless of the reason for the hair loss;

5. treatments for hair loss;

6. a procedure or surgery to remove fatty tissue such as panniculectomy (if determined to be cosmetic in nature), abdominoplasty, thighplasty, brachioplasty, or mastopexy;

7. varicose vein treatment of the lower extremities, when it is considered cosmetic; and

8. treatment of benign gynecomastia (abnormal breast enlargement in males).

Prescription Drugs (Including Specialty Medications)

The HSP covers prescription drugs provided while you are a hospital inpatient. The plan does not cover:

1. any prescription drug you obtain on an outpatient basis, except as specifically described as covered;

2. any prescription drug obtained illegally outside of the U.S., even if covered when purchased in the U.S;

3. drugs used for the treatment of erectile dysfunction, impotence, or sexual dysfunction or inadequacy;

4. immunizations related to travel or work;

5. injectable drugs, if an oral alternative is available;

6. needles, syringes and other injectable aids, except as covered for diabetic supplies;

7. over-the-counter drugs, biologicals or chemical preparations that can be obtained without a prescription;

8. performance-enhancing steroids;

9. self-injectable drugs;

10. services related to the dispensing, injection or application of a drug; or

11. treatment, drug, service or supply to:

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- stop or reduce smoking or the use of other tobacco products; or - treat or reduce nicotine addiction, dependence or cravings.

This exclusion includes (but is not limited to) counseling, hypnosis, medications, patches and gum.

Specialty Medications CVS Specialty, a Designated Dispensing Entity, is the preferred specialty pharmacy provider for CVS Health. Select specialty medications are covered only under your prescription drug benefit through CVS Specialty; therefore, such medications are excluded from coverage under this medical plan.

A list of specialty medications that are only covered under the prescription drug plan and must be dispensed by CVS Specialty is available by logging onto www.caremark.com. Since this list is subject to change, you should call (800) 237-2767 for the most current list of such medications. In general, the drugs on this list will not be covered by any pharmacy except for CVS Specialty, regardless of their medical necessity, their approval, or if the member has a prescription by a physician or other provider. However, in limited circumstances, coverage may be allowed through an alternate provider. Those circumstances include:

1. Specialty medications billed by a facility as part of an inpatient hospital stay.* 2. Specialty medications billed as part of an emergency room visit.* 3. Situations where Medicare is the primary carrier.* 4. Limited distribution specialty medications where CVS Caremark does not have

access to the drug.* 5. Circumstances where homecare is not clinically appropriate (either due to the

member’s clinical history or due to characteristics of the drug which require special handling) and an alternative infusion site (that is qualified to administer the drug) is not available for coordination of services within a reasonable proximity (30 miles or less).**

6. The treating physician has provided written documentation outlining the clinical rationale for the requirement that the member be treated at the designated facility and confirming that the designated facility is unable to accept drug dispensed by CVS Caremark. The written documentation will be reviewed and approved by appropriate CVS Caremark clinical personnel before allowing coverage for the requesting provider under the medical benefit.** *Prior approval by CVS Caremark is not required. **Situation will be evaluated by CVS Caremark clinical staff.

Prior authorization may be required for any specialty medication, regardless of whether it is filled through the prescription drug plan or the medical plan. In addition, for designated specialty medications where coverage is still allowed under the medical benefit, the drug, drug dosage(s) and site(s) of care for infusion therapy may require prior authorization for medical necessity, appropriateness of therapy and patient safety.

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Infusion Nursing and Site of Care Management for Specialty Medications Infusion nursing services for select specialty medications that are administered in the home and/or in an ambulatory infusion center are covered through the prescription drug plan and are coordinated through and dispensed by the CVS Specialty. For non-oncology infused specialty medications that require administration by a medical professional, a CareTeam nurse will work with you and your provider to assess your clinical history and determine clinically appropriate options (location for your infusion) for clinician-infused specialty medications. Options may include homecare, an ambulatory infusion center, physician office, etc. CareTeam nurses will contact all impacted members to provide assistance and guidance.

Providers

Services:

1. performed by a Provider who is a family member by birth or marriage, including your Spouse, brother, sister, parent or child;

2. a Provider may perform on himself or herself;

3. performed by a Provider with your same legal residence;

4. ordered or delivered by a Christian Science practitioner;

5. performed by an unlicensed Provider or a Provider who is operating outside of the scope of his/her license;

6. provided at a diagnostic facility (Hospital or free-standing) without a written order from a Provider;

7. which are self-directed to a free-standing or Hospital-based diagnostic facility; and

8. ordered by a Provider affiliated with a diagnostic facility (Hospital or free-standing), when that Provider is not actively involved in your medical care:

- prior to ordering the service; or - after the service is received.

This exclusion does not apply to mammography testing.

Reproduction

The following infertility treatment-related services:

■ Storage of reproductive materials such as sperm, eggs, embryos, ovarian tissue, and testicular tissue;

■ Surrogate parenting and host uterus;

■ The reversal of voluntary sterilization;

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■ Artificial reproductive treatments done for genetic or eugenic (selective breeding) purposes;

■ Services provided by a doula (labor aide);

■ Parenting, pre-natal or birthing classes;

■ oral contraceptives and contraceptive supplies (which are covered under your Prescription Drug benefit);(this exclusion does not apply to injectable contraceptives and diaphragms and IUDs);

■ Infertility services for couples in which one of the partners has had a previous elective sterilization procedure, with or without surgical reversal;

■ Infertility services for dependent children covered under the plan;

■ Purchase of donor sperm, donor eggs or donor embryos;

■ Cryopreservation* and storage of eggs, sperm or donor embryos;

■ All charges associated with gestational carrier programs for the gestational carrier;

■ Home ovulation prediction kits; and

■ Infertility services that are not reasonably likely to be successful.

*No coverage for cryopreservation unless for colleagues and covered spouses that will undergo planned cancer or other medical treatments that are likely to result in infertility.

Services Provided under Another Plan

Services for which coverage is available:

1. under another plan, except for Eligible Expenses payable as described in Section 10, Coordination of Benefits (COB);

2. under workers' compensation, no-fault automobile coverage or similar legislation if you could elect it, or could have it elected for you;

3. while on active military duty; and

4. for treatment of military service-related disabilities when you are legally entitled to other coverage, and facilities are reasonably accessible.

Transplants

1. health services for organ and tissue transplants,

- except as identified under Transplantation Services in Section 6, Additional Coverage Details unless UnitedHealthcare determines the transplant to be appropriate according to UnitedHealthcare’s transplant guidelines;

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2. mechanical or animal organ transplants, except services related to the implant or removal of a circulatory assist device (a device that supports the heart while the patient waits for a suitable donor heart to become available); and

3. donor costs incurred by a covered plan member in connection with transplanting an organ or tissue to a recipient who is not a covered plan member (these costs may be payable through the recipient’s benefit plan).

Travel

1. travel or transportation expenses, even if ordered by a Physician, except as identified under Travel and Lodging in Section 6, Additional Coverage Details.

Vision and Hearing

1. routine vision examinations, including refractive examinations to determine the need for vision correction;

2. implantable lenses used only to correct a refractive error (such as Intacs corneal implants);

3. surgery and other related treatment that is intended to correct nearsightedness, farsightedness, presbyopia and astigmatism including, but not limited to, procedures such as laser and other refractive eye surgery and radial keratotomy;

4. eyeglasses, contact lenses and hearing aids, including purchase and fitting; and

5. routine hearing exams in excess of one per Plan year.

All Other Exclusions

1. autopsies and other coroner services and transportation services for a corpse;

2. charges for:

- missed appointments; - room or facility reservations; - completion of claim forms; - record processing; or - services, supplies or equipment that are advertised by the Provider as free;

3. charges by a Provider sanctioned under a federal program for reason of fraud, abuse or

medical competency;

4. charges prohibited by federal anti-kickback or self-referral statutes;

5. chelation therapy, except to treat heavy metal poisoning;

6. Custodial Care as defined in Section 15, Glossary, or services provided by a personal care assistant;

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7. diagnostic tests that are:

- delivered in other than a Physician's office or health care facility; and - self-administered home diagnostic tests, including but not limited to HIV and

Pregnancy tests;

8. Domiciliary Care, as defined in Section 15, Glossary;

9. growth hormone therapy;

10. expenses for health services and supplies:

- that are received as a result of war or any act of war, whether declared or undeclared, while part of any armed service force of any country. This exclusion does not apply to Covered Persons who are civilians injured or otherwise affected by war, any act of war or terrorism in a non-war zone;

- that are received after the date your coverage under this plan ends, including health services for medical conditions which began before the date your coverage under the plan ends;

- for which you have no legal responsibility to pay, or for which a charge would not ordinarily be made in the absence of coverage under this Benefit Plan; or

- that exceed Eligible Expenses or any specified limitation in this SPD; - for which a non-Network Provider waives the Deductible or Coinsurance amounts;

11. foreign language and sign language services;

12. health services and supplies that do not meet the definition of a Covered Health Service – see the definition in Section 15, Glossary. Covered Health Services are those health services including services, supplies or Prescription Drugs, which the Claims Administrator determines to be all of the following:

- Medically Necessary; - described as a Covered Health Service in this Summary Plan Description; and - not otherwise excluded in this Summary Plan Description under this Section 8,

Exclusions. 13. 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 the plan 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.

14. medical and surgical treatment of snoring, except when provided as a part of treatment for documented obstructive sleep apnea (a sleep disorder in which a person regularly stops breathing for 10 seconds or longer). Appliances for snoring are always excluded;

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15. Private Duty Nursing;

16. respite care;

17. rest cures;

18. genetic testing for screening purposes or parentage testing;

19. spinal treatment to treat a condition unrelated to alignment of the vertebral column, such as asthma or allergies;

20. spinal treatment (including chiropractic and osteopathic manipulative therapy) including:

- services and supplies for analysis and adjustments of spinal subluxation; and - diagnosis and treatment by manipulation of the skeletal structure; - except as provided under Spinal Manipulation in Section 6, Additional Coverage Details.

21. storage of blood, umbilical cord or other material for use in a Covered Health Service,

except if needed for an imminent surgery;

22. the following treatments for obesity:

- non-surgical treatment (except as may be covered in conjunction with Nutritional or Obesity Counseling services), even if for morbid obesity; and

- surgical treatment of obesity unless there is a diagnosis of morbid obesity as described under Obesity Surgery in Section 6, Additional Coverage Details; and

23. treatment of hyperhidrosis (excessive sweating).

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89 SECTION 9 – CLAIMS AND APPEALS PROCEDURES

SECTION 9 – CLAIMS AND APPEALS PROCEDURES

What This Section Includes: ■ How Network and non-Network claims work; Procedures for submitting claims,

making decisions on claims; and what to do if your claim is denied, in whole or in part.

Network Benefits

In general, if you receive Covered Health Services from a Network Provider, UnitedHealthcare will pay the Physician or facility directly. If a Network Provider bills you for any Covered Health Service other than your Coinsurance, please contact the Provider or call UnitedHealthcare at the phone number on your ID card for assistance.

Keep in mind, you are responsible for meeting the Deductible and paying any Coinsurance owed to a Network Provider once you have received your Explanation of Benefits from UnitedHealthcare a bill from the Provider.

Non-Network Benefits

If you receive a bill for Covered Health Services from a non-Network Provider, you (or the Provider if they prefer) must send the bill to UnitedHealthcare for processing. To make sure the claim is processed promptly and accurately, a completed claim form must be attached and mailed to UnitedHealthcare at the address on the back of your ID card.

After UnitedHealthcare has processed your claim, you will receive payment for Benefits that the plan allows. UnitedHealthcare will pay Benefits to you unless:

■ the Provider notifies UnitedHealthcare that you have provided signed authorization to assign Benefits directly to that Provider; or

■ you make a written request for the non-Network Provider to be paid directly at the time you submit your claim.

UnitedHealthcare will only pay Benefits to you or, with written authorization by you, your Provider, and not to a third party, even if your Provider has assigned Benefits to that third party.

It is your responsibility to pay the non-Network Provider the charges you incurred, including any difference between what you were billed and what the plan paid.

Claims and Appeals

The plan has procedures for submitting claims, making decisions on claims and filing an appeal when you don’t agree with a claim decision. You and UnitedHealthcare must meet certain deadlines that are assigned to each step of the process, depending on the type of claim.

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Types of Claims

To understand the claim and appeal process, you need to understand how claims are defined. Following are the four types of claims:

■ Urgent care claim is a claim for medical care or treatment where delay could seriously jeopardize your life or health, or your ability to regain maximum function; or subject you to severe pain that cannot be adequately managed without the requested care or treatment.

■ Pre-service claim is a claim for a benefit that requires approval of the benefit in advance of obtain medical care (i.e. precertification).

■ Concurrent care claim extension is a request to extend a course of treatment that was previously approved.

■ Concurrent care claim reduction or termination is a decision to reduce or terminate a course of treatment that was previously approved.

■ Post-service claim is a claim for a benefit that is not a pre-service claim; and for which the service has been rendered and billed.

Keeping Records of Expenses

It is important to keep records of medical expenses for yourself and your covered dependents. You will need these records when you file a claim for Benefits. Be sure you have this information for your medical records:

■ Name and address of physicians;

■ Dates on which each expense was incurred; and

■ Copies of all bills and receipts.

Filing and Processing Claims

If you use an out-of-network provider, you must file a claim to be reimbursed for covered expenses. You can obtain a claim form by calling the toll-free number on the back of your ID card, or by visiting www.myuhc.com. The form has instructions on how, when and where to file a claim.

All claims must be filed promptly. The deadline for filing a claim is 12 months after the date you incur a covered expense. If, through no fault of your own, you are unable to meet that deadline, your claim will be accepted if you file it as soon as possible. Claims filed more than two years after the deadline will be accepted only if you had been legally incapacitated.

You may file claims for benefits and appeal any adverse claim decisions yourself or through an “authorized representative,” who is someone you authorize in writing to act on your behalf. The plan will also recognize a court order giving a person authority to submit claims on your behalf, except that in the case of a claim involving urgent care, a health care professional with knowledge of your condition may always act as your authorized representative.

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UnitedHealthcare will make a decision on your claim.

■ If United Healthcare approves the claim, UnitedHealthcare will send you an Explanation of Benefits (EOB) that shows you how UnitedHealthcare determined the benefit payment. UnitedHealthcare will pay any health benefits to the service provider, unless you give UnitedHealthcare different instructions when you file the claim. The EOB will let you know if there is any portion of the claim you need to pay.

■ If UnitedHealthcare denies your claim, in whole or in part, UnitedHealthcare must give you a written notice of the denial within the timeframes specified under Time Frames for Claims Processing. The EOB or notice will include the reason for the denial or partial payment and the review (appeal) procedures.

Keep in Mind ■ If you would like paper copies of the EOBs, you may call the toll-free number on

your ID card to request them.

■ You can also view and print all of your EOBs online at www.myuhc.com.

■ See Section 15, Glossary for the definition of Explanation of Benefits.

Time Frames for Claim Processing

The chart below shows when UnitedHealthcare must notify you if your claim has been denied.

Type of Claim UnitedHealthcare Must Notify You

Urgent care claim As soon as possible, but not later than 72 hours

The determination may be provided in writing, electronically or orally. If the determination has been provided orally, a written or electronic notification will be sent no later than 3 calendar days after the oral notification.

Pre-service claim 15 calendar days

Concurrent care claim extension

Urgent care claim – as soon as possible, but not later than 24 hours, provided the request was received at least 24 hours before the end of the approved treatment

Other claims – 15 calendar days

Concurrent care claim reduction or termination

With enough advance notice to allow you to appeal

Post-service claim 30 calendar days

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Extensions of Time Frames

The time periods described in the chart may be extended, as follows:

■ For urgent care claims: If UnitedHealthcare does not have enough information to decide the claim, you will be notified as soon as possible (but no more than 24 hours after UnitedHealthcare receives the claim) that additional information is needed. You will then have at least 48 hours to provide the information. A decision on your claim will be made within 48 hours after you provide the additional information.

■ For non-urgent pre-service and post-service claims: The time frames may be extended for up to 15 additional days for reasons beyond the plan’s control. In this case, UnitedHealthcare will notify you of the extension before the original notification time period has ended.

If an extension of time is needed because UnitedHealthcare needs more information to process your post-service claim:

- UnitedHealthcare will notify you and give you an additional period of at least 45 days after receiving the notice to provide the information.

- UnitedHealthcare will then inform you of the claim decision within 15 days after the additional period has ended (or within 15 days after UnitedHealthcare receives the information, if earlier).

If you do not provide the information, your claim will be denied.

Notice of Claim Denial

A claim denial is also called an adverse benefit determination. An adverse benefit determination is a decision UnitedHealthcare makes that results in denial, reduction or termination of:

■ A benefit; or

■ The amount paid for a service or supply.

It also means a decision not to provide a benefit or service. Adverse benefit determinations can be made for one or more of the following reasons:

■ The individual is not eligible to participate in the plan; or

■ UnitedHealthcare determines that a benefit or service is not covered by the plan because:

- It is not included in the list of covered benefits;

- It is specifically excluded;

- It is not medically necessary; or

- A plan limit or maximum has been reached.

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If your claim is denied, in whole or in part, UnitedHealthcare will send you written notice of an adverse benefit determination. The notice will give you:

■ The reason or reasons that your claim was denied;

■ A reference to the specific plan provisions on which the denial was based;

- If an internal rule, guideline, protocol or other similar criterion was relied upon to determine a claim, you’ll either receive:

♦ A copy of the actual rule, guideline, protocol or other criterion; or ♦ A statement that the rule, guideline, protocol or other criterion was used and that

you can request a copy free of charge.

- If the denial is based on a plan provision, such as medical necessity, experimental treatment, or a similar exclusion or limit, you’ll either receive:

♦ An explanation of the scientific or clinical judgment for the determination; or ♦ A statement that you can receive the explanation free of charge upon request.

■ Information sufficient to identify your claim;

■ A description of any additional material or information needed to perfect the claim and the reason why the material or information is necessary;

■ An explanation of the plan’s claim review and appeal procedures, applicable time limits and a statement of your rights to bring a civil action under ERISA section 502(a) after completing all required levels of appeal; and

■ An explanation of the expedited claim review process for an urgent care claim. In the case of an urgent care claim, the plan may notify you by phone or fax, then follow up with a written or electronic notice within three days of the notification.

Appealing a Medical Claim Decision

If you disagree with a claim determination, you may file an appeal, following the appeal process outlined below.

Three Steps in the Appeal Process The plan provides for two levels of appeal to UnitedHealthcare, plus an option to seek external review:

■ You must request your first appeal (level one) within 180 calendar days after you receive the notice of a claim denial.

■ If you are dissatisfied with the outcome of your level one appeal to UnitedHealthcare, you may ask for a second review (a level two appeal). You must request a level two appeal no later than 60 days after you receive the level one notice of denial.

■ After you have exhausted the level one and level two appeal process, you may file a voluntary appeal for external review if your claim meets certain requirements. You must

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submit a request for external review within four (4) months of the date you receive a final denial notice.

How to Appeal a Claim Denial Your level one and level two appeals may be submitted in writing or by making a phone call to UnitedHealthcare Member Services. Your appeal should include:

■ Patient’s name;

■ Your employer’s name;

■ A copy of UnitedHealthcare’s notice of the adverse benefit determination;

■ Your reasons for making the appeal; and

■ Any other documentation or written information to support your request that you would like to have considered.

You or your enrolled Dependent may send your appeal to:

UnitedHealthcare - Appeals P.O. Box 30432 Salt Lake City, UT 84130-0432

For Urgent Care requests for Benefits that have been denied, you or your Provider can call UnitedHealthcare at the toll-free number on your ID card to request an appeal.

Based on the type of claim, UnitedHealthcare must respond to your appeal within the time frames shown in the chart below.

Type of Claim Level One Appeal Level Two Appeal

Urgent care claim 24 hours 24 hours

Pre-service claim 15 calendar days 15 calendar days

Concurrent care claim extension

Treated like an urgent care claim or a pre-service claim, depending on the circumstances

Treated like an urgent care claim or a pre-service claim, depending on the circumstances

Post-service claim 30 calendar days 30 calendar days

If requested, you will be given reasonable access to, and copies of, all documents, records, or other information relevant to your claim, free of charge, and the identity of any medical expert consulted in connection with your initial claim (regardless of whether the expert’s advice was used to deny your claim).

Upon receipt of your appeal, UnitedHealthcare will make a full and fair review of your claim, taking into account all comments, documents, records and other information submitted by you (regardless of whether the information was submitted or considered in determining your initial claim). The review will not defer to UnitedHealthcare’s prior decision. If UnitedHealthcare’s claim denial was based on medical judgment, UnitedHealthcare will consult with a medical professional who has appropriate training and experience in the field

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of medicine involved in the medical judgment and who was neither consulted in connection with its prior decision nor a subordinate of any such person. Before UnitedHealthcare makes its appeal determination, if applicable, you will be provided, free of charge, any new or additional evidence considered, relied upon, or generated by UnitedHealthcare (or at the direction of UnitedHealthcare) or any or additional rationale as soon as possible and in sufficient time to allow you the opportunity to respond before UnitedHealthcare issues its appeal determination.

The review will be performed by plan personnel who were not involved in making the adverse benefit determination.

You may also choose to have another person (an authorized representative) make the appeal on your behalf by providing written consent to UnitedHealthcare. In the cast of an urgent care claim or a pre-service claim, a physician familiar with the case may represent you in the appeal.

If your appeal is approved, UnitedHealthcare will notify you in writing. If your appeal is denied, in whole or in part, you will receive a written notice that will explain:

■ The specific reason(s) for the adverse benefit determination;

■ References to the specific plan provisions on which the adverse benefit determination was based;

■ A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim;

■ Information sufficient to identify your claim;

■ Any internal procedures or clinical information upon which the adverse benefit determination was based (or a statement that this information will be provided free of charge, upon request);

■ If the adverse benefit determination is based on a medical necessity, either an explanation of the scientific or clinical judgment for the denial, applying the terms of the plan to your medical circumstances (or a statement that this explanation will be provided free of charge, upon request); and

■ The plan’s available review procedures, including information about the plan’s external review procedures. The notice will also state that you have the right to bring a civil action under Section 502(a) of ERISA after your claims and appeals process is exhausted.

If the level one and level two appeals uphold the original adverse benefit determination for a medical claim, you may have the right to pursue an external review of your claim. See External Review for details.

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Exhaustion of Internal Appeals Process Generally, you must complete all the plan’s appeal levels before asking for an external review or bringing an action in litigation. However, if UnitedHealthcare (or the plan or its designee) does not strictly adhere to all claim determination and appeal requirements under applicable federal law, you are considered to have exhausted the plan’s appeal requirements. This is known as deemed exhaustion. When this occurs, you may proceed with external review or pursue any available remedies under §502(a) of ERISA or under state law, as applicable.

Exception: There is an exception to the deemed exhaustion rule. You cannot submit your claim or internal appeal directly to external review if the rule violation was:

■ Minor and not likely to influence a decision or harm you; and

■ For a good cause or was beyond UnitedHealthcare’s or the plan’s (or its designee’s) control; and

■ Part of an ongoing good faith exchange between you and UnitedHealthcare or the plan; and

■ Not part of a pattern or practice of violations by UnitedHealthcare or the plan.

If the claims procedures have not been strictly adhered to, you have the right to request a written explanation of the violation from UnitedHealthcare or the plan. Within 10 days after receiving your request, UnitedHealthcare or the plan will give you an explanation of the basis, if any, for asserting that the violation should not cause the internal claim and appeal process to be deemed exhausted. If an external reviewer or court rejects your request for immediate review on the basis that the plan met the standards for the exception, you have the right to resubmit your claim and pursue the internal appeal of the claim.

External Review

You may file a voluntary appeal for external review of any final appeal determination that qualifies. An external review is a review of an adverse benefit determination by an Independent Review Organization (IRO).

If you file for a voluntary external review, any applicable statute of limitations will be tolled (suspended) while the appeal is pending. The filing of a claim will have no effect on your rights to any other benefits under the plan. However, the appeal is voluntary and you are not required to undertake it before pursuing legal action.

Keep in Mind You do not have to file for voluntary review. After you exhaust the plan’s two standard levels of appeal, you may pursue any available remedies under Section 502(a) of ERISA. Your decision to decline the voluntary review process is not considered a failure to exhaust your administrative remedies.

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Claims That Qualify for External Review

You may request an external review of a rescission (coverage that was cancelled or discontinued retroactively) or a claim denial based on medical judgment if:

■ You have exhausted the plan’s appeal process; or

■ UnitedHealthcare (or the plan or its designee) has not strictly followed all claim determination and appeal requirements under federal law (except for minor violations).

A denial based upon your eligibility does not qualify for external review.

You must complete all of the levels of standard appeal before you can request an external review, except in a case of deemed exhaustion (see Exhaustion of the Internal Appeals Process above for an explanation of deemed exhaustion). Your authorized representative may act on your behalf in filing and pursuing this voluntary appeal, subject to any plan verification procedures.

Deadline for Requesting an External Review

You must submit a request for external review within four (4) months of the date you receive a final denial notice. If the last filing date would fall on a Saturday, Sunday or federal holiday, the last filing date is extended to the next day that is not a Saturday, Sunday or federal holiday. You also must include a copy of the notice and all other pertinent information that supports your request.

Any request for external review must be made in writing, except in the case of an urgent care medical claim, which can also be made orally.

Preliminary Review

UnitedHealthcare will do a preliminary review of your request for an external review within five (5) business days of receiving the request. The preliminary review determines whether:

■ You were covered under the plan at the time the service was requested or provided;

■ The adverse determination does not relate to eligibility;

■ You have exhausted the internal appeals process (unless deemed exhaustion applies); and

■ You have provided all paperwork necessary to complete the external review.

UnitedHealthcare must notify you in writing of the results of the preliminary review within one (1) business day after completing the review.

■ If your request is complete but not eligible for external review, UnitedHealthcare’s notice will include the reasons why it is not eligible and provide contact information for the Employee Benefits Security Administration (toll-free number 1-866-444-3272).

■ If the request is not complete, UnitedHealthcare’s notice will describe the information or materials needed to make the request complete. UnitedHealthcare will allow you to

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perfect the request for external review within the four months filing period or within the 48-hour period following the receipt of the notification, whichever is later.

Referral to IRO

If your request for external review is approved, UnitedHealthcare will assign an accredited IRO to conduct the review. The IRO will notify you in writing that your request is eligible and accepted for review, and give you an opportunity to submit additional information within 10 business days for a non-emergency (standard) external review.

A neutral, independent clinical reviewer, with appropriate expertise in the area in question, will review your material. The decision of the external reviewer is binding unless otherwise allowed by law.

The IRO will review all of the information and documents received within required time frames. In reaching a decision, the assigned IRO will not be bound by any decisions or conclusions reached during the plan’s claims and appeals process. The IRO will consider the following in reaching a decision, as appropriate:

■ Your medical records;

■ The attending health care professional's recommendation;

■ Reports from appropriate health care professionals and other documents submitted by the plan or issuer, you or your treating provider;

■ The terms of your plan to ensure that the IRO's decision is not contrary to the terms of the plan, unless the terms are inconsistent with applicable law;

■ Appropriate practice guidelines, which must include applicable evidence-based standards and may include any other practice guidelines developed by the federal government, national or professional medical societies, boards and associations;

■ Any applicable clinical review criteria developed and used by Aetna, unless the criteria are inconsistent with the terms of the plan or with applicable law; and

■ The opinion of the IRO's clinical reviewer or reviewers after considering the information described in this notice to the extent the information or documents are available and the clinical reviewer or reviewers consider appropriate.

The assigned IRO must provide written notice of the final decision within 45 days after receiving the request for external review. The IRO must deliver the final decision to you, UnitedHealthcare and the plan.

The IRO’s notice will contain:

■ A general description of the reason for the request for external review, including information sufficient to identify the claim (e.g., the date or dates of service, the health care provider, the claim amount, the diagnosis code and its meaning, the treatment code and its meaning, and the reasons for the previous denials).

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■ The date the IRO received the external review assignment from UnitedHealthcare and the date of the IRO’s decision.

■ References to the evidence or documentation, including specific coverage provisions and evidence-based standards, that the IRO considered in making its determination.

■ A discussion of the principal reason(s) for the IRO’s decision, including the rationale for the decision, and any evidence-based standards that were relied upon by the IRO in making its decision.

■ A statement that the determination is binding, except to the extent that other remedies may be available under state or federal law to either the plan or you.

■ A statement that you may still be eligible to seek judicial review of any adverse external review determination.

■ Current contact information, including the telephone number, for any applicable office of health insurance consumer assistance or ombudsmen available to assist you.

If the IRO’s Final External Review Decision reverses UnitedHealthcare’s adverse benefit determination, the plan will accept the decision and provide the benefits for the service or procedure in accordance with the terms and conditions of the plan. If the IRO’s decision confirms UnitedHealthcare’s adverse benefit determination, the plan will not be obligated to provide benefits for the service or procedure.

Expedited External Review

The plan must allow you to request an expedited external review at the time:

■ You receive an adverse benefit determination, if:

- That determination involves a medical condition for which the timeframe for completing an expedited internal appeal (the standard level one and level two appeal process) would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function; and

- You have filed a request for an expedited internal appeal; or

■ You exhaust the internal appeal process (level one and level two), if:

- You have a medical condition where the timeframe for completing a standard external review would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function; or

- It concerns an admission, availability of care, continued stay, or health care item or service for which you received emergency services, but have not been discharged from a facility.

As soon as UnitedHealthcare receives your request for an expedited external review, UnitedHealthcare will determine whether the request meets the reviewability requirements for standard external review and immediately notify you of its determination.

If your request for an expedited external review is approved, UnitedHealthcare will assign an IRO, and forward your request to the IRO (electronically, by telephone or fax, or by another

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similar manner) along with all documents and information it considered in making its adverse benefit determination.

The IRO will follow the review process described above and make a decision as quickly as your medical condition or circumstances require, and within 72 hours after the IRO receives your request for the expedited review. If the IRO gives you its decision orally, the IRO must follow up with written confirmation to you, UnitedHealthcare and the plan within 48 hours of making the decision.

Legal Action

If you believe your claim under the plan is being improperly denied in whole or in part, you have the right to bring legal action. However, no legal action can be brought until you have exhausted all the steps in the appeal process provided in the plan. You must bring any such legal action within three years of the date you are notified of the final decision on your appeal or you lose any rights to bring such an action.

Complaints

The plan has procedures for you to follow if you are dissatisfied with the service you receive from the plan or you want to complain about an-network provider. To make a complaint about an operational issue or the quality of care you’ve received, you must write to Member Services within 30 days of the incident. Include a detailed description of the matter and include copies of any records or documents that you think are relevant. UnitedHealthcare will review the information and give you a written decision within 30 calendar days of the receipt of the complaint, unless additional information is needed, but cannot be obtained within this time frame. The notice of the decision will tell you what you need to do to seek an additional review.

Recovery of Overpayment

If UnitedHealthcare makes a benefit payment over the amount that you are entitled to under this plan, UnitedHealthcare has the right to:

■ Require that the overpayment be returned on request; or

■ Reduce any future benefit payment by the amount of the overpayment.

This right does not affect any other right of overpayment recovery UnitedHealthcare may have.

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101 SECTION 10 – COORDINATION OF BENEFITS

SECTION 10 - COORDINATION OF BENEFITS (COB)

What This Section Includes: ■ How your Benefits under the HSP coordinate with other medical plans;

■ How coverage is affected if you become eligible for Medicare; and

■ Procedures in the event the HSP overpays Benefits.

Coordination of Benefits (COB) applies to you if you are covered by more than one health benefits plan, including any one of the following:

■ another employer sponsored health benefits plan;

■ a medical component of a group long-term care plan, such as skilled nursing care;

■ no-fault or traditional "fault" type medical payment benefits or personal injury protection benefits under an auto insurance policy;

■ medical payment benefits under any premises liability or other types of liability coverage; or

■ Medicare or other governmental health benefit.

If coverage is provided under two or more plans, COB determines which plan is primary and which plan is secondary. The plan considered primary pays its benefits first, without regard to the possibility that another plan may cover some expenses. Any remaining expenses may be paid under the other plan, which is considered secondary. The secondary plan may determine its benefits based on the benefits paid by the primary plan.

Determining Which Plan Is Primary

If you are covered by two or more plans, the benefit payment follows the rules below in this order.

■ The HSP will always be secondary to medical payment coverage or personal injury protection coverage under any auto liability or no-fault insurance policy.

■ When you have coverage under two or more medical plans and only one has COB provisions, the plan without COB provisions will pay benefits first.

■ A plan that covers a person as an employee pays benefits before a plan that covers the person as a dependent.

■ If you are receiving COBRA continuation coverage under another employer plan, the HSP will pay Benefits first.

■ Your Dependent children will receive primary coverage from the parent whose birth date occurs first in a calendar year. If both parents have the same birth date, the plan that pays benefits first is the one that has been in effect the longest. This birthday rule applies only if: the parents are married or living together whether or not they have ever been married and not legally separated; or a court decree awards joint custody without specifying that one party has the responsibility to provide health care coverage; if two or

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more plans cover a Dependent child of divorced or separated parents and if there is no court decree stating that one parent is responsible for health care, the child will be covered under the plan of:

- the parent with custody of the child; then - the Spouse of the parent with custody of the child; then - the parent not having custody of the child; then - the Spouse of the parent not having custody of the child.

■ Plans for active employees pay before plans covering laid-off or retired employees.

■ The plan that has covered the individual claimant the longest will pay first; only expenses normally paid by the HSP will be paid under COB.

■ Finally, if none of the above rules determines which plan is primary or secondary, the allowable expenses shall be shared equally between the plans meeting the definition of plan. In addition, the HSP will not pay more than it would have paid had it been the primary plan.

The following examples illustrate how the HSP determines which plan pays first and which plan pays second.

Determining Primary and Secondary Plan – Examples

1) Let's say you and your Spouse both have family medical coverage through your respective employers. You are not well and go to see a Physician. Since you're covered as an Employee under the HSP, and as a Dependent under your Spouse's plan, the HSP will pay Benefits for the Physician's office visit first.

2) Again, let's say you and your Spouse both have family medical coverage through your respective employers. You take your Dependent child to see a Physician. The HSP will look at your birthday and your Spouse's birthday to determine which plan pays first. If you were born on June 11 and your Spouse was born on May 30, your Spouse's plan will pay first.

When This Plan Is Secondary

If the HSP is secondary, it determines the amount it will pay for a Covered Health Service by following the steps below.

■ The HSP determines the amount it would have paid based on the primary plan's allowable expense.

■ If the HSP would have paid less than the primary plan paid, the HSP pays no Benefits.

■ If the HSP would have paid more than the primary plan paid, the HSP will pay the difference.

The maximum combined payment you can receive from all plans may be less than 100% of the total allowable expense.

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Determining the Allowable Expense When This Plan Is Secondary When the HSP is secondary, the allowable expense is the primary plan's Network rate. If the primary plan bases its reimbursement on reasonable and customary charges, the allowable expense is the primary plan's reasonable and customary charge. If both the primary plan and the HSP do not have a contracted rate, the allowable expense will be the greater of the two plans' reasonable and customary charges.

What Is An Allowable Expense? For purposes of COB, an allowable expense is a health care expense that is covered at least in part by one of the health benefit plans covering you.

When a Covered Person Qualifies for Medicare

Determining Which Plan Is Primary To the extent permitted by law, the HSP will pay Benefits second to Medicare when you become eligible for Medicare, even if you don't elect it. There are, however, Medicare-eligible individuals for whom the HSP pays Benefits first and Medicare pays benefits second:

■ Employees with active current employment status age 65 or older and their Spouses age 65 or older; and

■ Individuals with end-stage renal disease, for a limited period of time.

Determining the Allowable Expense When This Plan Is Secondary If the HSP is secondary to Medicare, the Medicare approved amount is the allowable expense, as long as the Provider accepts Medicare. If the Provider does not accept Medicare, the Medicare limiting charge (the most a Provider can charge you if they don't accept Medicare) will be the allowable expense. Medicare payments, combined with plan Benefits, will not exceed 100% of the total allowable expense.

If you are eligible for, but not enrolled in, Medicare, and the HSP is secondary to Medicare, Benefits payable under the HSP will be reduced by the amount that would have been paid if you had been enrolled in Medicare.

Medicare Crossover Program

The Plan offers a Medicare Crossover program for Medicare Part A and Part B and Durable Medical Equipment (DME) claims. Under this program, you no longer have to file a separate claim with the Plan to receive secondary benefits for these expenses. Your Dependent will also have this automated crossover, as long as he or she is eligible for Medicare and this Plan is your only secondary medical coverage.

Once the Medicare Part A and Part B and DME carriers have reimbursed your health care provider, the Medicare carrier will electronically submit the necessary information to the Claims Administrator to process the balance of your claim under the provisions of this Plan.

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You can verify that the automated crossover took place when your copy of the explanation of Medicare benefits (EOMB) states your claim has been forwarded to your secondary carrier.

This crossover process does not apply to expenses that Medicare does not cover. You must continue to file claims for these expenses.

For information about enrollment or if you have questions about the program, call the telephone number listed on the back of your ID card.

Right to Receive and Release Needed Information

Certain facts about health care coverage and services are needed to apply these COB rules and to determine benefits payable under the HSP and other plans. The Plan Administrator may get the facts needed from, or give them to, other organizations or persons for the purpose of applying these rules and determining benefits payable under this Plan and other plans covering the person claiming benefits.

The Plan Administrator does not need to tell, or get the consent of, any person to do this. Each person claiming benefits under the HSP must give UnitedHealthcare any facts needed to apply those rules and determine benefits payable. If you do not provide UnitedHealthcare the information needed to apply these rules and determine the Benefits payable, your claim for Benefits will be denied.

Overpayment and Underpayment of Benefits

If you are covered under more than one medical plan, there is a possibility that the other plan will pay a benefit that UnitedHealthcare should have paid. If this occurs, the HSP may pay the other plan the amount owed.

If the HSP pays you more than it owes under this COB provision, you should pay the excess back promptly. Otherwise, the Company may recover the amount in the form of salary, wages, or benefits payable under any Company-sponsored benefit plans, including the HSP. The Company also reserves the right to recover any overpayment by legal action or offset payments on future Eligible Expenses.

If the HSP overpays a health care Provider, UnitedHealthcare reserves the right to recover the excess amount, by legal action if necessary.

Refund of Overpayments If the HSP pays for 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 the plan if:

■ 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 the plan made exceeded the Benefits under the HSP; or

■ all or some of the payment was made in error.

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The refund equals the amount the HSP paid in excess of the amount that should have paid under the plan. If the refund is due from another person or organization, the Covered Person agrees to help the HSP get the refund when requested.

If the Covered Person, or any other person or organization that was paid, does not promptly refund the full amount, the HSP may reduce the amount of any future Benefits for the Covered Person that are payable under the plan. The reductions will equal the amount of the required refund. CVS may have other rights in addition to the right to reduce future Benefits.

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106 SECTION 11-– SUBROGATION AND REIMBURSEMENT

SECTION 11 - RIGHTS OF SUBROGATION, REIMBURSEMENT AND RECOVERY

What This Section Includes: ■ How Benefits paid on your behalf are impacted if you suffer a Sickness or Injury

allegedly caused by a third party; and

■ The HSP’s right to recover Benefits that are considered the responsibility of a third party to pay.

The provisions of this section apply to anyone on whose behalf the plan pays or has paid benefits (“you” or “your”), including all current and former plan participants, as well as, for purposes of the obligations under this section, all persons acting on behalf of an individual who receives or has received benefits under the plan, such as the parents, guardians or other representatives of a dependent child or the personal representatives of an individual’s estate, decedents, minors and incompetent or disabled persons. No adult may assign any rights that he or she may have to any minor child(ren) without the prior written informed and express consent of the plan.

The plan’s right of subrogation, reimbursement, and recovery, as set forth below, extends to all insurance coverage available to you due to an injury, illness or condition for which the plan has paid medical claims, including (but not limited to):

■ Liability coverage;

■ Uninsured motorist coverage;

■ Underinsured motorist coverage;

■ Personal umbrella coverage;

■ Medical payments coverage;

■ Workers’ compensation coverage;

■ No fault automobile coverage; or

■ Any first party insurance coverage.

Your health plan is always secondary to automobile no-fault coverage, personal injury protection coverage or medical payments coverage.

No disbursement of any settlement proceeds or other recovery funds from any insurance coverage or other source will be made until the health plan’s subrogation and reimbursement interests are fully satisfied.

Subrogation

The right of subrogation means the plan is entitled to pursue any claims that you may have in order to recover the benefits paid by the plan. Immediately upon paying or providing any benefit under the plan, the plan shall be subrogated to (stand in the place of) all of your rights of recovery with respect to any claim or potential claim against any party, due to an injury, illness or condition to the full extent of benefits provided or to be provided by the

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plan. The plan may assert a claim or file suit in your name and take appropriate action to assert its subrogation claim, with or without your consent. The plan is not required to pay you part of any recovery it may obtain, even if it files suit in your name.

Reimbursement

If you receive any payment as a result of an injury, illness or condition, you agree to reimburse the plan first from such payment for all amounts the plan has paid and will pay as a result of that injury, illness or condition, up to and including the full amount of your recovery.

When You Accept Plan Benefits

By accepting benefits (whether the payment of such benefits is made to you or made on your behalf to any provider) you agree to the following rules:

■ Constructive trust: If you receive any payment as a result of an injury, illness or condition, you will serve as a constructive trustee over those funds. Failure to hold such funds in trust will be deemed a breach of your fiduciary duty to the plan. No disbursement of any settlement proceeds or other recovery funds from any insurance coverage or other source will be made until the plan’s subrogation and reimbursement interest are fully satisfied.

■ Lien rights: The plan will automatically have a lien to the extent of benefits paid by the plan for the treatment of the illness, injury or condition upon any recovery whether by settlement, judgment or otherwise, related to treatment for any illness, injury or condition for which the plan paid benefits. The lien may be enforced against any party who possesses funds or proceeds representing the amount of benefits paid by the plan, including (but not limited to) you, your representative or agent, and/or any other source that possessed or will possess funds representing the amount of benefits paid by the plan.

■ Assignment: In order to secure the plan’s recovery rights, you agree to assign to the plan any benefits or claims or rights of recovery you have under any automobile policy or other coverage, to the full extent of the plan’s subrogation and reimbursement claims. This assignment allows the plan to pursue any claim you may have, whether or not you choose to pursue the claim.

■ First-priority claim: By accepting benefits from the plan, you acknowledge that the plan’s recovery rights are a first priority claim and are to be repaid to the plan before you receive any recovery for your damages. The plan shall be entitled to full reimbursement on a first-dollar basis from any payments, even if such payment to the plan will result in a recovery which is insufficient to make you whole or to compensate you in part or in whole for the damages sustained. The plan is not required to participate in or pay your court costs or attorney fees to any attorney you hire to pursue your damage claim.

■ Cooperation: You agree to cooperate fully with the plan’s efforts to recover benefits paid. It is your duty to notify the plan within 30 days of the date when any notice is given to any party, including an insurance company or attorney, of your intention to pursue or investigate a claim to recover damages or obtain compensation due to your injury, illness or condition. You and your agents agree to provide the plan or its representatives notice

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of any recovery you or your agents obtain prior to receipt of such recovery funds or within 5 days if no notice was given prior to receipt. Further, you and your agents agree to provide notice prior to any disbursement of settlement or any other recovery funds obtained. You and your agents shall provide all information requested by the plan, the Claims Administrator or its representative, including (but not limited to) completing and submitting:

■ Any applications or other forms or statements as the plan may reasonably request; and

■ All documents related to or filed in personal injury litigation.

- Failure to provide this information, failure to assist the plan in pursuit of its subrogation rights or failure to reimburse the plan from any settlement or recovery you receive may result in the denial of any future benefit payments or claim until the plan is reimbursed in full, termination of your health benefits or the institution of court proceedings against you.

- You shall do nothing to prejudice the plan’s subrogation or recovery interest or prejudice the plan’s ability to enforce the terms of this plan provision. This includes (but is not limited to) refraining from making any settlement or recovery that attempts to reduce or exclude the full cost of all benefits provided by the plan or disbursement of any settlement proceeds or other recovery prior to fully satisfying the plan’s subrogation and reimbursement interest.

- You acknowledge that the plan has the right to conduct an investigation regarding the injury, illness or condition to identify potential sources of recovery. The plan reserves the right to notify all parties and his/her agents of its lien. Agents include, but are not limited to, insurance companies and attorneys.

- You acknowledge that the plan has notified you that it has the right pursuant to the Health Insurance Portability & Accountability Act (“HIPAA”), 42 U.S.C. Section 1301 et seq, to share your personal health information in exercising its subrogation and reimbursement rights.

■ Jurisdiction: By accepting benefits from the plan, you agree that any court proceeding with respect to this provision may be brought in any court of competent jurisdiction as the plan may elect. By accepting such benefits, you hereby submit to each such jurisdiction, waiving whatever rights may correspond by reason of your present or future domicile. By accepting such benefits, you also agree to pay all attorneys’ fees the plan incurs in successful attempts to recover amounts the plan is entitled to under this section.

Applicability to All Settlements and Judgments

The terms of this entire subrogation and right of recovery provision shall apply and the plan is entitled to full recovery regardless of whether any liability for payment is admitted and regardless of whether the settlement or judgment identifies the medical benefits the plan provided or purports to allocate any portion of such settlement or judgment to payment of expenses other than medical expenses. The plan is entitled to recover from any and all settlements or judgments, even those designated as pain and suffering, non-economic

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damages and/or general damages only. The plan’s claim will not be reduced due to your own negligence.

Interpretation

In the event that any claim is made that any part of this subrogation and right of recovery provision is ambiguous or questions arise concerning the meaning or intent of any of its terms, the Claims Administrator for the plan shall have the sole authority and discretion to resolve all disputes regarding the interpretation of this provision.

Right of Recovery

The plan also has the right to recover benefits it has paid on the beneficiary’s behalf that are:

■ Made in error;

■ Made due to a mistake in fact;

■ Advanced during the time period in which the beneficiary is required to meet and has not yet met the plan year Deductible under the plan; or

■ Advanced during the time period in which the beneficiary is required to meet and has not yet met the Out-of-Pocket Maximum for the plan year.

Benefits paid because the beneficiary misrepresents facts are also subject to recovery by the plan.

If the plan provides the beneficiary a benefit that exceeds the amount that should have been paid, the plan will:

■ Require that the overpayment be immediately returned when requested, or

■ Reduce a future benefit payment for the beneficiary or his or her Dependents by the amount of the overpayment.

In addition, if the plan makes payments with respect to allowable expenses in excess of the maximum amount of payment necessary to satisfy the terms of the plan, the plan shall have the right, exercisable in its sole discretion, to recover such excess payments.

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110 SECTION 12 – WHEN COVERAGE ENDS

SECTION 12 - WHEN COVERAGE ENDS

What This Section Includes: ■ Circumstances that cause coverage to end; and

■ How to continue coverage after it ends.

Your HSP coverage under the plan can end for a number of reasons. This section explains how and why your coverage can be terminated, and how you may be able to continue coverage after it ends.

Your entitlement to Benefits automatically ends on the date that coverage ends, even if you are hospitalized or are otherwise receiving medical treatment on that date.

When your coverage ends, the plan will still pay claims for Covered Health Services that you received before your coverage ended. However, once your coverage ends, Benefits are not provided for health services that you receive after coverage ended, even if the underlying medical condition occurred before your coverage ended.

For Employees Your HSP coverage will end on the earliest of:

■ the date your employment with the Company ends;

■ the date the coverage described in this booklet is terminated under the plan;

■ the date you stop making the required contributions;

■ the date you are no longer in an eligible class for all or part of your coverage;

■ the date you retire; or

■ the date you decide to discontinue coverage.

For Dependents Your Dependent’s coverage will end on the earliest of:

■ the date your coverage ends;

■ the date your Dependent becomes covered as an Employee;

■ the date you stop making the required contributions for Dependent coverage;

■ the last day of the calendar month during which your Dependent child turns age 26 (except with regard to disabled children);

■ the date that you become divorced or legally separated;

■ the date you disenroll your Dependent as provided under the plan (for example, due to a Change in Status);

■ the date your Dependent no longer meets the Dependent eligibility requirements under the plan;

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■ the date Dependent coverage under the plan is terminated; or

■ the date the plan is terminated.

Note that you are required to provide notice by going to myHR at myhr.cvs.com or by calling myHR at 1-888-MY-HR-CVS (1-888-694-7287) no later than 30 days following your Dependent ceasing to be eligible under the plan.

The plan will provide written notice to you that your coverage has ended if any of the following occur:

■ you permit an unauthorized person to use your ID card or you use another person's ID card;

■ you knowingly give UnitedHealthcare false material information including, but not limited to, false information relating to another person's eligibility or status as a Dependent;

■ you commit an act of physical or verbal abuse that imposes a threat to CVS's staff, UnitedHealthcare's staff, a Provider or another Covered Person; or

■ you violate any terms of the plan.

Note: CVS has the right to demand that you pay back Benefits CVS paid to you, or paid in your name, during the time you were incorrectly covered under the HSP.

Rescissions of Coverage

Fraud and Misrepresentation The plan may rescind (i.e., cancel or discontinue on a retroactive basis) coverage if you or your Dependents perform an act, practice, or omission that constitutes fraud or makes an intentional misrepresentation of material fact. If the rescission relates to medical or prescription coverage, you and/or your Dependents (as applicable) will receive at least 30 days advance notice before the coverage is rescinded.

Administrative Delays and Failure to Pay Premiums Coverage may be retroactively terminated due to administrative delays in processing or due to a failure to timely pay required premiums or contributions toward the cost of coverage. Except where required by law, coverage may be terminated for these reasons without advance notice.

Erroneous Claims and Administrative Errors

If the Claims Administrator determines that a benefit was paid under the HSP that either (a) exceeds the covered expenses or (b) was paid in error (for example, if the HSP provided coverage to an ineligible Dependent), you will be required to repay to the HSP the improperly covered benefits. The plan provides that the Claims Administrator in its discretion may recoup the improperly covered benefits under any method of collection available, including any of the following:

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■ notification to you of the error, and an accompanying request that you immediately pay the amount of the improperly covered benefit as directed by the Claims Administrator;

■ offsetting the amount of the improperly covered benefit against any other eligible plan benefits (regardless of the Plan Year in which it is submitted; and

■ if permissible under applicable law, withholding the amount of the improperly covered benefits from your pay on a post-tax basis.

If the Claims Administrator is unable to recover all or a portion of your debt to the plan, you may not be eligible to participate in the plan during the next Annual Enrollment period.

Loss of Benefits

You or your Dependents also may experience a reduction or loss of benefits in any of the following circumstances:

■ You fail to follow the plan’s procedures.

■ You fail to reimburse the HSP for a claim that was paid in error.

■ You receive reimbursement for a covered expense by another similar insurance plan which is primary to the HSP while also receiving primary reimbursement from the plan.

■ You receive a judgment, settlement or otherwise from any person or entity with respect to the sickness, injury or other condition which gives rise to expenses the plan pays.

■ You are found to have committed a fraudulent act against the plan including, but not limited to, the fraudulent filing of a claim for reimbursement.

■ The plan is amended or terminated, but only with respect to expenses incurred after the amendment or termination becomes effective.

■ You or your provider fails to file a claim within 12 months of the date service is provided.

Continuation Coverage under the Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA)

Under a federal law called the Uniformed Services Employment and Reemployment Rights Act of 1994 (“USERRA”), you have certain rights regarding continuance of benefits while you are on a leave of absence for military service or uniformed service (referred to herein as a “military leave of absence”). The terms “uniformed services” or “military service” mean the Armed Forces, the Army National Guard and the Air National Guard when engaged in active duty for training, inactive duty training, or full-time National Guard duty, the commissioned corps of the Public Health Service, and any other category of persons designated by the President in time of war or national emergency. A “leave of absence” is a predetermined period of time in which you are not working for CVS. You are, however, expected to return to active employment at the end of your leave of absence.

It is CVS’s policy to allow Employees on a military leave of absence to continue health coverage for up to 12 months at the active-employee cost. If you continue to be on a military leave of absence at the time the foregoing 12-month period is exhausted, under

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USERRA, you may elect to continue your coverage for an additional 24 months (or if less, for the period you are on military leave) by paying for the full cost of the benefits plus a 2% administrative charge under COBRA. Under USERRA, covered Dependents also have a right to continue their health coverage during the Employee’s period of military leave of absence.

Regardless of whether you choose to continue coverage while on a military leave of absence, if you return to a position of employment with CVS, your health coverage and that of your eligible Dependents will be reinstated, provided you call myHR at 1-888-MY-HR-CVS (1-888-694-7287) or go to myhr.cvs.com within 30 days of your return to work. If you do not call myHR or visit myhr.cvs.com and follow the necessary steps for reenrollment, you will be required to wait until the Annual Enrollment period to reinstate your coverage. Reinstatement of coverage is not automatic. No exclusions or waiting period may be imposed on you or your eligible Dependents in connection with this reinstatement, unless a sickness or injury is determined by the Secretary of Veterans Affairs to have been incurred in, or aggravated during, the performance of military service.

For more information about filing for coverage while you are on a military leave of absence, and applicable costs, call myHR at 1-888-MY-HR-CVS (1-888-694-7287).

Continuing Coverage during Family and Medical Leave Act (FMLA) Leave

All eligible participants who have worked for CVS for at least one year and worked at least 1,250 hours over the previous 12 months are covered under a federal law called the Family and Medical Leave Act (FMLA). According to this law, you are eligible for at least 12 weeks of unpaid leave for the following reasons:

■ the birth or adoption of your child or placement of a child with you for adoption or foster care (you must take the leave within one year of the birth, adoption, or placement);

■ a serious health condition of your child, Spouse, or parent;

■ your own serious health condition that prevents you from performing the duties of your job (this condition must involve inpatient care or continuing treatment by a health care provider);

■ a qualifying exigency arising out of the fact that your Spouse, child, or parent is a covered military member on active duty (or has been notified of an impending call or order to active duty) as a member of the National Guard or Reserves in support of a contingency operation; or

■ for up to 26 work weeks during a single 12-month period to care for a covered current service member with a serious injury or illness, but only if you are the child, parent, or next-of-kin (as defined in regulations) with respect to the service member.

If you experience a qualifying FMLA leave event and want to take a leave of absence under FMLA, you should first discuss it with your supervisor as soon as possible. You must then contact the Leave of Absence Department to initiate your leave by logging onto myhr.cvs.com (select the myLeave link and follow the prompts) or by calling myHR at 1-

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888-MY-HR-CVS (1-888-694-7287) (and following the prompts to the Leave of Absence Department.

If you take a leave of absence under FMLA, you may continue your medical coverage during the leave period by continuing to pay the required contributions.

To the extent any portion of your FMLA leave is paid leave, you will continue to have your benefit contributions deducted from your pay. Otherwise, you must submit your contributions on an after-tax basis. If your required contribution during FMLA leave is more than 30 days late, your coverage will be terminated in accordance with the FMLA retroactive to the date through which you have paid for coverage.

If you acquire a new Dependent while your coverage is continued during an approved FMLA leave, the Dependent will be eligible for continued coverage on the same terms as would be applicable to you if you were actively at work, not on an approved FMLA leave.

If you choose not to continue your coverage while on a FMLA leave, you will not be reimbursed for any benefit claims incurred while you are on the FMLA leave. To reinstate your coverage upon a return from a leave of absence, you must do so within 30 days of returning from your leave, by either calling myHR at 1-888-MY-HR-CVS (1-888-694-7287) or going to myhr.cvs.com. If you do not call myHR or visit myhr.cvsc.com and follow the necessary steps for reenrollment, you will be required to wait until the Annual Enrollment period to reinstate your coverage. Reinstatement of coverage is not automatic.

If you do not return to work after your FMLA leave ends, you may be allowed to continue your coverage at the active-employee rate under another CVS leave policy (provided premiums are paid). Otherwise, your coverage at the active-employee rate will terminate (although as described below you and your Dependents may have COBRA continuation coverage rights).

If your medical coverage ends because your approved FMLA leave is considered terminated by CVS, you and your Dependents may, on the date of such termination, be eligible to elect to continue your coverage under COBRA. COBRA continuation coverage will be available on the same terms as though your employment terminated, for reasons other than for gross misconduct, on such date.

State Family and Medical Leave Laws CVS’ FMLA policy complies with any state law that provides greater family or medical leave rights than those provided under this FMLA policy. If your leave qualifies under the FMLA and under a state law, you will receive the greater benefit.

If CVS Changes Benefits If CVS offers new benefits or changes its benefits while you are on an FMLA leave, you are eligible for the new or changed benefits, but your contributions for these benefits may increase.

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Continuing Coverage during Leaves of Absences (Other than FMLA or USERRA)

Company-Approved Leaves If you are on a CVS-approved leave of absence (other than a personal leave or military leave of absence), it is CVS’s policy to allow you and your Dependents to continue your medical coverage under the plan for up to 180 days at the active-employee rate, provided you continue to pay premiums to CVS, unless your collective bargaining agreement indicates otherwise. If you continue to be on a company-approved leave of absence at the end of the foregoing 180 day period, you may be eligible to elect to continue your health coverage under COBRA. COBRA continuation coverage will be available on the same terms as though your employment terminated, for reasons other than for gross misconduct. Under COBRA you must pay the full cost of the benefits plus a 2% administrative charge.

Personal Leaves If you are on a personal leave of absence, it is CVS’s policy to allow you and your Dependents to continue your medical coverage under the plan for up to 30 days at the active-employee rate, provided you continue to pay premiums to CVS. If you continue to be on a leave of absence at the end of the foregoing 30-day period, you may be eligible to elect to continue your coverage under COBRA. COBRA continuation coverage will be available on the same terms as though your employment terminated (for reasons other than gross misconduct). Under COBRA you must pay the full cost of the benefits plus a 2% administrative charge.

Return from Leave If you choose not to continue your coverage while on a CVS-approved leave of absence (including a personal leave), you may reinstate your coverage when you return to work. Reinstatement of coverage is not automatic. When you return to work, call myHR at 1-888-MY-HR-CVS (1-888-694-7287) or visit myhr.cvs.com within 30 days of returning from your FMLA leave to re-enroll in the plan. If you do not call myHR or visit myhr.cvs.com and follow the necessary steps for reenrollment within the first 30 days of returning to work, you will be required to wait until the Annual Enrollment period to reinstate your coverage.

Continuing Coverage under COBRA

If you lose your plan coverage, you may have the right to extend it under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as defined in Section 15, Glossary.

The plan is responsible for making COBRA coverage available to you, and for complying with all of COBRA’s requirements. You should call myHR or the COBRA Administrator if you have any questions about COBRA.

This health plan is subject to the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), which requires that you and your Dependents be given the opportunity for a temporary extension of health coverage (called “continuation coverage”) at group rates in certain instances where coverage otherwise would end due to the occurrence of a “qualifying event”. Thus, in accordance with COBRA and as described below, if you are no longer eligible to participate in the plan due to a qualifying event, you and your covered Spouse and covered Dependents will be entitled to continue coverage under COBRA as described

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below. You may continue only the plan coverage in effect at the time of the qualifying event and must pay required premiums.

Qualifying Events and Continuation Periods The chart below outlines:

■ the qualifying events that trigger the right to continue coverage;

■ those eligible to elect continued coverage; and

■ the maximum continuation period.

Qualifying Event Causing Loss of Coverage

Covered Persons Eligible for Continued Coverage

Maximum Continuation Period

Termination of active employment (except for gross misconduct)

You Your Spouse

Your Dependent children

18 months

Reduction in work hours You Your Spouse


18 months

Termination of active employment due to military leave (USERRA)

You Your Spouse


24 months

Divorce or legal separation or termination of a domestic partnership

Your Spouse Your Dependent children

36 months

Children no longer qualify as eligible for Dependent coverage

Your Dependent children 36 months

You become entitled to Medicare benefits under the Social Security Act (under Part A, Part B, or both)

Your Spouse Your Dependent children

36 months – see discussion below

Your death Your Spouse Your Dependent children

36 months

Medicare Extension for Your Dependents If the qualifying event is your termination of employment or reduction in work hours and you became enrolled in Medicare (Part A, Part B, or both) within the 18 months before the qualifying event, COBRA continuation coverage for your Dependents will last up to 36 months after the date you became enrolled in Medicare. Your COBRA continuation coverage will last for 18 months from the date of your termination of employment or reduction in work hours.

Covered Person’s Responsibility You or your covered Dependents must notify myHR at 1-888-MY_HR_CVS (1-888-694-7287) to advise them of a divorce, legal separation, or when a covered Dependent ceases to be a Dependent under the terms of the Plan, within 60 days of such event. Failure to do so will result in the loss of the right to elect to continue coverage under this continuation of coverage provision. Notice must be given prior to the qualifying event, or as soon as possible thereafter, and no later than 60 days after the qualifying event occurs.

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If you or your covered Dependents fail to provide myHR with timely notice when one of these qualifying events occurs, the right to COBRA coverage will be waived. A Covered Person who elects COBRA coverage will have the same enrollment rights that apply to active Employees.

CVS’s Responsibility For other qualifying events (your end of employment or reduction of hours of employment or your death), CVS will notify the COBRA Administrator. Upon notice of a qualifying event, the COBRA Administrator will notify you and your covered Dependents (individually or jointly) of the right to elect COBRA coverage.

Disability Extension

If you or your covered Dependents qualify for disability status under Title II or XVI of the Social Security Act at the time of a reduction in hours or termination of employment, or are determined to be disabled within 60 days of beginning COBRA coverage, all Covered Persons with respect to the disabled individual(s) may extend the continuation period for an additional 11 months for up to a total of 29 months. To extend the coverage beyond the 18-month period, you or your covered Dependent must notify the COBRA Administrator of the Social Security Administration’s (“SSA’s”) determination within 60 days after the later of:

■ the date of the SSA’s determination,

■ the date on which the qualifying event occurs under the plan, or

■ the date on which you or your covered Dependent are informed of your responsibility to provide notice of your disability to the COBRA Administrator and of the plan’s procedures for providing such notice (which are included in this Summary), and

■ in all cases before the end of the 18-month period of COBRA coverage.

Notice must be provided in writing to the COBRA Administrator and must be sent, along with a copy of the SSA’s disability determination, to the COBRA Administrator at the address listed under the “COBRA Contact Information” heading within the COBRA section of this Summary.

If there is a determination by the SSA that you or the applicable covered Dependent is no longer disabled, the COBRA Administrator must be notified of that fact within 30 days of the SSA’s determination. Upon receipt of this notice, COBRA coverage extended beyond the maximum period that would otherwise apply will be terminated on the first day of the month which is 30 days after the determination that you or your covered Dependent is no longer disabled.

Second Qualifying Events

If you or your covered Dependents experience another qualifying event while already on COBRA coverage due your termination of employment or reduction in hours, your covered Dependents may elect to extend the period of COBRA coverage for up to 36 months from the date of termination or reduction in hours, provided notice of the second qualifying event is properly given (as described below).

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For example, assume that you and your covered Dependents elect COBRA coverage because of your termination of employment. If you die during the first 18 months of COBRA coverage, your covered Dependents could elect to continue COBRA coverage for up to 36 months from your date of termination.

A Covered Person must notify the COBRA Administrator of the second qualifying event within 60 days of the second qualifying event. This notice must be provided in writing to the COBRA Administrator at the address listed under the “COBRA Contact Information” heading below within the COBRA section of this Summary.

Election You and your covered Dependents are entitled to a period of 60 days in which to elect to continue coverage under the plan. The 60-day election period begins on the date you or your covered Dependents would lose plan coverage because of one of the qualifying events described above and ends on the later of 60 days following such date or the date the notice is sent about eligibility to elect to continue coverage.

If you or your covered Dependents elect continuation coverage within the 60-day election period, continuation coverage will generally begin on the date your plan coverage (as an active Employee) ceases. Even if you or your covered Dependents waive continuation coverage, but within the 60-day election period revoke the waiver, continuation coverage will also begin on the date your plan coverage (as an active Employee) ceases. A waiver may not be revoked after the end of the 60 day election period.

If you or your covered Dependents do not choose continuation coverage within the 60-day election period, eligibility for continuation coverage ends at the end of that period.

Acquiring New Dependents during Continuation If you acquire any new Dependents during a period of continuation (through birth, adoption or marriage), they can be added for the remainder of the continuation period if:

■ they meet the definition of an eligible Dependent;

■ you notify your Employer within 30 days of their eligibility; and

■ you pay the additional required premiums.

Cost of Continuation Coverage To receive continuation coverage, you or your covered Dependents, or any third party, must pay the required monthly premium plus a two percent administrative charge (102%) for the 18- or 36-month continuation period. If you or your covered Dependents are eligible for an extension of coverage due to disability, the cost of the continuation coverage will be 150% of the normal required monthly premium for all months after the 18th month of continuation coverage.

Each monthly premium for continuation coverage is due on the first day of the month for which coverage is being continued. However, the first such monthly premium is not due until 45 days after the date on which you and/or your covered Dependents initially elect continuation coverage.

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Benefits under Continuation Coverage If you or your covered Dependents choose continuation coverage, the coverage is identical to the coverage being provided to similarly situated Employees, and their covered Dependents who have not experienced a qualifying event. If their coverage changes, continuation coverage will change in the same way.

Payment of Claims No claim will be payable under this continuation of coverage provision until the applicable premium is paid to the COBRA Administrator.

When COBRA Continuation Coverage Ends Coverage under this continuation of coverage provision will terminate on the earliest of:

■ the date the required monthly premium is due, if you or your covered Dependents fail to make payment within 30 days after the due date;

■ the end of the applicable continuation coverage period described above;

■ the date on which CVS ceases to provide a group health plan to any Employee;

■ the date you or your covered Dependents first become covered under any other group health plan after electing continuation coverage, provided that the new plan does not contain any pre-existing condition exclusion that would affect the Covered Person's coverage under the new plan;

■ the date you or your covered Dependents become entitled to Medicare benefits under Title XVIII of the Social Security Act after electing continuation coverage; or

■ the date you or your Dependents die.

In no case will coverage extend beyond 36 months from the original qualifying event, even if a second qualifying event occurs during the continuation coverage period.

If You Have Questions Questions concerning your plan or your COBRA continuation coverage rights should be addressed to the contact(s) identified below. For more information about your rights under the Employee Retirement Income Security Act of 1974, as mended (“ERISA”), including COBRA, the Health Insurance Portability and Accountability Act (“HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.)

Keep Your COBRA Administrator Informed of Address Changes In order to protect your and your covered Dependents’ rights, you should keep the COBRA Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the COBRA Administrator.

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COBRA Contact Information Information regarding your COBRA continuation coverage can be obtained upon request from the COBRA Administrator, as listed below.

AonHewitt P.O. Box 563927 Charlotte, NC 28256

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121 SECTION 13 – OTHER IMPORTANT INFORMATION

SECTION 13 - OTHER IMPORTANT INFORMATION

What This Section Includes: ■ Court-ordered Benefits for Dependent children;

■ Your relationship with UnitedHealthcare and CVS;

■ Relationships with Providers;

■ Incentives to Providers and you;

■ Workers compensation not affected;

■ Interpretation of Benefits;

■ Your privacy rights under HIPAA; and

■ Your ERISA Rights

Qualified Medical Child Support Orders (QMCSOs)

The HSP complies with the requirements of any “Qualified Medical Child Support Order” (QMSCO), as defined in Section 609(a)(2)(A) of ERISA. A medical child support order is a judgment, decree or order issued by a court of competent jurisdiction or appropriate state agency that:

■ provides for child support with respect to your child under a group health plan or provides for health benefit coverage for your child; and

■ is made pursuant to a state domestic relations law (including a community property law), and relates to benefits under the company’s health care plan.

A QMCSO creates or recognizes the existence of an Alternate Recipient’s rights to — or assigns to an Alternate Recipient the right to — receive benefits for which you are eligible under the plan. The Plan Administrator has developed procedures to determine whether a medical child support order is qualified and for complying therewith. A Covered Person may obtain, without charge, a copy of these procedures upon request to the Plan Administrator.

Generally, a QMCSO is issued as part of a paternity, divorce, or other child support settlement. If the Plan receives a medical child support order for your child that instructs the Plan to cover the child, the Plan Administrator will review it to determine if it meets the requirements for a QMCSO. If it determines that it does, your child will be enrolled in the Plan as your Dependent, and the plan will be required to pay Benefits as directed by the order.

Note: A National Medical Support Notice will be recognized as a QMCSO if it meets the requirements of a QMCSO.

Coverage extends to a child covered under a QMSCO if:

■ The QMSCO is issued on or after the date you become eligible to enroll in the plan even if you elected not to, and the child meets the plan’s definition of an eligible Dependent.

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Your Relationship with UnitedHealthcare and CVS

In order to make choices about your health care coverage and treatment, CVS believes that it is important for you to understand how UnitedHealthcare interacts with the plan and how it may affect you. UnitedHealthcare helps administer the plan in which you are enrolled. UnitedHealthcare does not provide medical services or make treatment decisions. This means:

■ CVS and UnitedHealthcare do not decide what care you need or will receive. You and your Physician make those decisions;

■ UnitedHealthcare communicates to you decisions about whether the 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 SPD); and

■ 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.

The Plan Administrator and UnitedHealthcare may use individually identifiable information about you to identify for you (and you alone) procedures, products or services that you may find valuable. The Plan Administrator and UnitedHealthcare may use individually identifiable information about you as permitted or required by law, including in operations and in research. The Plan Administrator and UnitedHealthcare may use de-identified data for commercial purposes including research.

Relationship with Providers

The relationships between CVS and UnitedHealthcare and Network Providers (and to the extent a member received care under the Harvard Pilgrim Network, Harvard Pilgrim Health Care) are solely contractual relationships between independent contractors. Network Providers are not CVS's agents or employees, nor are they agents or employees of UnitedHealthcare CVS and any of its employees are not agents or employees of Network Providers, nor is UnitedHealthcare and any of its employees agents or employees of Network Providers.

CVS and UnitedHealthcare do not provide health care services or supplies, nor do they practice medicine. Instead, CVS, and UnitedHealthcare arranges for health care Providers to participate in a Network and pay Benefits. Network Providers are independent practitioners who run their own offices and facilities. UnitedHealthcare's (and Harvard Pilgrim Health Care’s) credentialing processes confirm public information about the Providers' licenses and other credentials, but do not assure the quality of the services provided. They are not CVS's employees nor are they employees of UnitedHealthcare. CVS, and UnitedHealthcare do not have any other relationship with Network Providers such as principal-agent or joint venture. CVS and UnitedHealthcare are not liable for any act or omission of any Provider.

UnitedHealthcare and Harvard Pilgrim Health Care are not considered to be employers of the Plan Administrator for any purpose with respect to the administration or provision of benefits under this Plan.

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The Plan Administrator is solely responsible for:

■ enrollment and classification changes (including classification changes resulting in your enrollment or the termination of your coverage);

■ the timely payment of Benefits; and

■ notifying you of the termination or modifications to the plan.

Your Relationship with Providers

The relationship between you and any Provider is that of Provider and patient. Your Provider is solely responsible for the quality of the services provided to you. You:

■ are responsible for choosing your own Provider;

■ are responsible for paying, directly to your Provider, any amount identified as a member responsibility, including Coinsurance, any Deductible and any amount that exceeds Eligible Expenses;

■ are responsible for paying, directly to your Provider, the cost of any non-Covered Health Service;

■ 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); and

■ must decide with your Provider what care you should receive.

Incentives to Providers

Network Providers may be provided financial incentives by UnitedHealthcare 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; or

■ a practice called capitation which is when a group of Network Providers receives a monthly payment from UnitedHealthcare for each Covered Person who selects a Network Provider within the group to perform or coordinate certain health services. The Network Providers receive this monthly payment regardless of whether the cost of providing or arranging to provide the Covered Person's health care is less than or more than the payment.

If you have any questions regarding financial incentives you may contact the telephone number on your ID card. You can ask 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. In addition, you may choose to discuss these financial incentives with your Network Provider.

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Incentives to You

Sometimes you may be offered coupons or other incentive 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 CVS recommends that you discuss participating in such programs with your Physician. These incentives are not Benefits and do not alter or affect your Benefits. You may call the number on the back of your ID cared if you have any questions.

Workers' Compensation Not Affected

Benefits provided under the plan do not substitute for and do not affect any requirements for coverage by workers' compensation insurance.

Interpretation of Benefits

The Plan Administrator and UnitedHealthcare have the sole and exclusive discretion to:

■ interpret Benefits under the plan;

■ interpret the other terms, conditions, limitations and exclusions of the plan, including this SPD and any Riders and/or Amendments; and

■ make factual determinations related to the plan and its Benefits.

The Plan Administrator and UnitedHealthcare may delegate this discretionary authority to other persons or entities that provide services in regard to the administration of the plan.

In certain circumstances, for purposes of overall cost savings or efficiency, the plan may, in its discretion, offer Benefits for services that would otherwise not be Covered Health Services. The fact that the plan does so in any particular case shall not in any way be deemed to require the plan to do so in other similar cases.

Your Privacy Rights under the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

We understand that your health information is private, and we are committed to maintaining the privacy of your medical information. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) gives you certain rights to privacy concerning your health information. The plan will follow the policies below to help ensure that your health information (or “protected health information” (“PHI”)) is protected and remains private.

Each time you submit a claim to the plan for reimbursement, and each time you see a health care provider who is paid by the plan, a record is created. The record may contain your PHI. In general, the plan will only use or disclose your PHI without your authorization for the specific reasons detailed below. Except in limited circumstances, the amount of information used or disclosed will be limited to the minimum necessary to accomplish the intent of the use or disclosure.

The plan does not operate by itself but rather is operated and administered by CVS and UnitedHealthcare acting on the plan's behalf. As a result, PHI used or disclosed by the plan

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(as discussed below) necessarily means that CVS and UnitedHealthcare, as applicable are using or disclosing the PHI on behalf of the plan. As a result, references to the plan in this section shall also be construed as references to CVS and UnitedHealthcare to the extent necessary to carry out the actions of the plan.

Permitted Uses and Disclosures The following categories describe different ways that the Plan may use or disclose your medical information. Not every use or disclosure in a category will be listed. However, all of the ways the plan is permitted to use and disclose information will fall within one of the categories.

The plan may use or disclose your PHI for the following reasons:

■ for treatment, payment, and health care operations;

■ to family members, relatives, and close personal friends involved in your care or payment for your care (but only to the extent of their involvement);

■ as required by law;

■ to avert a serious threat to your health and safety or the health and safety of the public or another person;

■ for purposes of organ or tissue donation;

■ as required by military command authorities, if you are a member of the armed forces;

■ for workers’ compensation or similar programs;

■ for public health activities (for example, to prevent or control disease, injury, or disability, to report reactions to medications or problems with products, etc.);

■ for certain health oversight activities (for example, audit and inspection to monitor the health care system);

■ in response to a court or administrative order or subpoena or discovery request;

■ to the Department of Health and Human Services for purposes of determining the plan’s compliance with these privacy rules;

■ to coroners, medical examiners, and funeral directors (for example, to identify a deceased person or determine the cause of death);

■ for national security and intelligence activities; and

■ if you are an inmate of a correctional institution for specified reasons such as the protection of your health and safety.

Disclosures to CVS

The plan will disclose your PHI to CVS for Plan administration purposes only upon receipt of a certification from CVS that the plan sets forth the permitted uses and disclosures of PHI by CVS on behalf of the Plan, and that CVS has agreed to the following assurances:

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■ CVS shall implement administrative, technical, and physical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of electronic PHI that it creates, receives, maintains, or transmits on behalf of the plan;

■ CVS shall not further use or disclose your PHI other than as permitted or required by the plan documents or as required by law;

■ CVS shall ensure that any agents, including subcontractors, to whom it provides PHI received from the plan agree to the same restrictions and conditions that apply to CVS with respect to such information and agree to implement reasonable and appropriate security measures to protect such information;

■ CVS shall not use or disclose PHI for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of CVS;

■ CVS shall report to the plan any use or disclosure of PHI that is inconsistent with the permitted uses and disclosures, including any security incidents, of which it becomes aware;

■ CVS shall make its internal practices, books, and records relating to the use and disclosure of PHI received from the plan available to the Department of Health and Human Services for purposes of determining whether the plan is complying with applicable regulations;

■ CVS shall, if feasible, return or destroy all PHI received from the plan about you and retain no copies of the information when it is no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, to limit further uses or disclosures to those purposes that make such return or destruction infeasible;

■ CVS shall ensure that there is adequate separation between the plan and CVS (as described below) and that the separation is supported by reasonable and appropriate security measures;

■ CVS shall make your PHI available to you (as described below);

■ CVS shall make your PHI available to you for amendment and incorporate any amendment into your PHI (as described below); and

■ CVS shall make available the information required to provide you an accounting of disclosures (as described below).

Access to PHI

The plan will make your PHI available to you for inspection and copying upon your written request to UnitedHealthcare. The plan may charge a fee for the costs of copying, mailing or other supplies associated with your request. The plan may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to PHI, you may request that the denial be reviewed.

Amendment of Medical Information

If you feel that PHI the plan has about you is incorrect or incomplete, you may ask the plan to amend the information. You have the right to request an amendment for as long as the

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information is kept by or for the plan. Your request must be made in writing and submitted to UnitedHealthcare. In addition, you must provide a reason that supports your request.

UnitedHealthcare may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, UnitedHealthcare may deny your request if you ask UnitedHealthcare to amend information that is not part of the medical information kept by or for the plan; was not created by the plan, unless the person or entity that created the information is no longer available to make the amendment; is not part of the information which you would be permitted to inspect and copy; or is accurate and complete.

Accounting of Disclosures

If you wish to know to whom your PHI has been disclosed for any purpose other than (a) treatment, payment, or health care operations, (b) pursuant to your written authorization, and (c) for certain other purposes, you may make a written request to UnitedHealthcare.

Your request must state a time period which may not be longer than six years. Your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a 12-month period will be free. The accounting will not include disclosure for the purposes of treatment, payment, or health care operations (provided, that, to the extent required by law, if the Plan maintains an electronic health record, the accounting will include such disclosures made through an electronic health record). In addition, the accounting will not include disclosures which you have authorized in writing.

Separation between the Plan and CVS

Only Employees of CVS, who are involved in the day-to-day operation and administrative functions of the plan will have access to your medical information. In general, this will only include the following individuals: Employees of the Human Resources Department and the Legal and Employee Relations Departments. These individuals will receive appropriate training regarding the plan’s privacy policies. In the event an individual fails to comply with the plan’s provisions regarding the protection of your medical information, CVS will take appropriate action in accordance with its established policy for failure to comply with the plan’s privacy provisions.

Other Uses of PHI

Any other uses and disclosures of your PHI will be made only with your written authorization. If you provide the plan authorization to use or disclose your PHI, you may revoke that authorization, in writing, at any time. If you revoke your authorization, the plan will no longer use or disclose your PHI for the reasons covered by your written authorization. Please note that the plan is unable to take back any disclosures it has already made with your authorization.

If you have a question about your rights under the HIPAA regulations, call myHR at 1-888-MY-HR-CVS (1-888-694-7287).

Electronic Data Security Standards

The plan will apply the following provisions to enable it to use and disclose electronic PHI as necessary to comply with the requirements of the HIPAA “Security Standards”

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promulgated under the Health Insurance Portability and Accountability Act of 1996 (the “Security Regulation”) relating to the use and disclosure of PHI that is maintained in an electronic format (“Electronic PHI”).

■ CVS will implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the Electronic PHI that it creates, receives, maintains or transmits on behalf of the plan.

■ CVS will ensure that the separation requirements applicable to the plan described above are supported by reasonable and appropriate data security measures to limit access to Electronic PHI to authorized users.

■ CVS will ensure that any agent, including a subcontractor, to whom it provides Electronic PHI, agrees to implement reasonable and appropriate security measures to protect the information.

■ CVS will report to the plan any security incident (within the meaning of 45 C.F.R. § 164.304) of which it becomes aware.

■ The plan and CVS will take any such further action as is required to comply with the Security Regulation.

Data Breach Reporting

As provided by Title XIII of the American Recovery and Reinvestment Act of 2009 and the related final regulations issued by the Department of Health and Human Services (“Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules Under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; Other Modifications to the HIPAA Rules” as set forth in Parts 160 and 164 of Title 45 of the Code of Federal Regulations), the plan and/or its vendors will provide notice of any “breach” of security involving unsecured PHI to the affected individuals and to the Department of Health and Human Services, as applicable.

If you have a question about your rights under the HIPAA regulations, call myHR at 1-888-MY-HR-CVS (1-888-694-7287).

Your ERISA Rights

As a participant in the CVS Health Welfare Benefit Plan (the “Plan”) under which the HSP is a component benefit plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to:

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 HSP, 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;

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■ Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the HSP, 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 copies; and

■ 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.

Continue Group Health Plan Coverage ■ Continue health care coverage for yourself, Spouse or Dependents if there is a loss of

coverage under the HSP as a result of a qualifying event. 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.

■ A reduction or elimination of exclusionary periods of coverage for pre-existing conditions under your group health plan, if you have creditable coverage from 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;

■ you become entitled to elect COBRA continuation coverage;

■ your COBRA continuation coverage ceases;

■ if you request it before losing coverage; or

■ if you request it up to 24 months after losing coverage.

■ Without evidence of creditable coverage, you may be subject to a pre-existing condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage.

Prudent Actions by Plan Fiduciaries In addition to creating rights for plan participants, ERISA imposes duties on the people who are responsible for the operation of the HSP. The people who operate your HSP, 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 plan Benefit or exercising your rights under ERISA.

Enforce Your Rights If your claim for a plan 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. See Section 9, Claims Procedures, for details.

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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 a 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 for reasons beyond the control of the Plan 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.

■ if you disagree with the plan’s decision or lack thereof concerning the qualified status of a domestic relations order, you may file suit in federal court.

■ if it should happen that the plan’s 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 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.

Assistance with Your Questions 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 write to:

Division of Technical Assistance and Inquiries Employee Benefits Security Administration U.S. Department of Labor 200 Constitution Avenue N.W. Washington, DC 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 at (800) 998-7542.

HEALTH SAVINGS PLAN

131 SECTION 14 – IMPORTANT ADMINISTRATIVE INFORMATION

SECTION 14 - IMPORTANT ADMINISTRATIVE INFORMATION

What This Section Includes: ■ This section includes information on the administration of the Health Savings Plan

(HSP), as well as information required of all Summary Plan Descriptions by ERISA as defined in Section 15, Glossary. While you may not need this information for your day-to-day participation, it is information you may find important.

Plan Information

ERISA Plan Name: The Health Savings Plan for CVS Health is a component plan under the CVS Health Welfare Benefit Plan.

ERISA Plan Number: The plan number for the CVS Health Welfare Benefit Plan, under which the HSP is a component plan, is 510.

Federal Employer ID: The Employer Identification Number (EIN) assigned to CVS Pharmacy, Inc. by the Internal Revenue Service is 05-0340626.

ERISA Plan Type: The HSP is a component health plan under the CVS Health Welfare Benefit Plan.

Plan Year: The plan records are kept on a 12-month period beginning June 1 and ending May 31.

Plan Administration: The HSP is self-insured and administered by UnitedHealthcare

Source of Plan Contributions: Employer and Employee

Source of Benefits: Assets of the Company

Plan Sponsor CVS Pharmacy, Inc. (and its participating affiliates) sponsors the CVS Health Welfare Benefit Plan. A complete list of employers sponsoring the Plan is available for examination and may be obtained by written request to the Plan Administrator.

You may contact the Plan Sponsor at:

CVS Pharmacy, Inc. One CVS Drive Woonsocket, RI 02895 (401) 765-1500

HEALTH SAVINGS PLAN


Plan Administrator The Plan Administrator is the Executive Vice President and Chief Human Resources Officer of CVS Pharmacy, Inc. Communications to the Plan Administrator should be directed as follows:

Attn: Lisa Bisaccia Executive Vice President and Chief Human Resources Officer CVS Pharmacy, Inc. One CVS Drive Woonsocket, RI 02895 401-765-1500

Except to the extent delegated, the Plan Administrator has the sole discretionary authority to interpret the terms of the plan. The Plan Administrator has delegated to UnitedHealthcare the discretionary authority to determine all claims under the plan. Such discretionary authority is intended to include, but is not limited to, the determination of whether a person is entitled to benefits under the plan and the computation of any and all benefit payments. The Plan Administrator also delegates to UnitedHealthcare the discretionary authority to perform a full and fair review, as required by ERISA, of each claim denial which has been appealed by a claimant or his or her duly authorized representative.

Except with regard to administrative authority delegated to UnitedHealthcare, the Plan Administrator shall have the sole discretionary authority to construe the terms of the plan and all facts surrounding claims under the plan (such as whether an individual is eligible for coverage under the plan), and shall determine all questions arising in the administration, interpretation and application of the plan. All determinations of the Plan Administrator shall be conclusive and binding on all parties.

Claims Administrator UnitedHealthcare is the Plan's Claims Administrator. The role of the Claims Administrator is to handle the day-to-day administration of the plan's coverage as directed by the Plan Administrator, through an administrative agreement with the Company. As Claims Administrator, UnitedHealthcare receives, processes, and pays for the benefits under the plan. With regard to administrative authority delegated to the Claims Administrator, the Claims Administrator shall have the sole discretionary authority to construe the terms of the plan and all facts surrounding claims under the plan, and shall determine all questions arising in the administration, interpretation and application of the plan. All determinations of the Claims Administrator shall be conclusive and binding on all parties.

The Claims Administrator shall not be deemed or construed as an employer for any purpose with respect to the administration or provision of Benefits under the Plan Sponsor's plan. The Claims Administrator shall not be responsible for fulfilling any duties or obligations of an employer with respect to the Plan Sponsor's plan.

HEALTH SAVINGS PLAN


You may contact the Claims Administrator by phone at the number on your ID card or in writing at:

UnitedHealthcare Services, Inc. 9900 Bren Road East Minnetonka, MN 55343

Agent for Service of Legal Process Should it ever be necessary, you or your personal representative may serve legal process on the agent of service for legal process for the plan. The plan's Agent of Service is:

CT Corporation System 155 South Main Street, Suite 301 Providence, RI 02903 Process may also be served on the Plan Administrator.

Named Fiduciary The named fiduciary is the Executive Vice President of Human Resources of CVS Pharmacy, Inc. Communications to be named fiduciary should be directed to:

Attn: Lisa Bisaccia Executive Vice President and Chief Human Resources Officer CVS Pharmacy, Inc. One CVS Drive Woonsocket, RI 02895 (401) 765-1500

A fiduciary exercises discretionary authority or control over management of the plan or the disposition of its assets, renders investment advice to the plan, or has discretionary authority or responsibility in the administration of the plan.

The “Named Fiduciary” is the one named in the plan, which is the Plan Administrator. The named fiduciary can appoint others to carry out fiduciary responsibilities under the plan. To the extent that the named fiduciary allocates its responsibility to other persons, the named fiduciary will generally not be liable for any act or omission of such person.

Claims Fiduciary While the Plan Administrator is the Named Fiduciary, UnitedHealthcare is the Claims Administrator, and is the plan fiduciary with respect to decisions regarding whether a claim for benefits will be paid under the plan.

COBRA Administrator AonHewitt myHR P.O. Box 563927 Charlotte, NC 28256

HEALTH SAVINGS PLAN


myHR

CVS Health P. O. Box 1135 Woonsocket, RI 02895 Attention: FSS Benefits Administration 1-888-MY-HR-CVS (1-888-694-7287)

Plan is Not an Employment Contract

Enrollment in the plan is not to be construed as a contract for or of employment. Accordingly, nothing in this document says or should be read to imply that participation in the plan is a guarantee of continued employment with CVS.

Future of the Plan

The continued maintenance of the plan is completely voluntary on the part of CVS and neither its existence nor its continuation will be construed as creating any contractual right to or obligation for its future continuation. While CVS expects to continue the plan indefinitely, CVS reserves the right at any time and for any reason, in its sole discretion, to curtail benefits under, otherwise amend, modify, or terminate the plan or any portion thereof without notice, including, without limitation, those portions of the plan outlining the benefits provided or the classes of Employees or Dependents eligible for benefits under the plan. The plan may be amended by the Board of Directors of CVS Health Corporation, by the Management Planning and Development Committee, or in certain circumstances, by approval of the Executive Vice President and Chief Human Resources Officer of CVS Pharmacy, Inc. Any claims requested after the effective date of termination, modification, or amendment are payable in accordance with the respective plan documents. However, no amendment or termination can reduce or otherwise affect any claim for a benefit you became entitled to before the date of amendment or termination. In the event the plan terminates, you will be informed of any termination rights you may have.

HEALTH SAVINGS ACCOUNT

135 SECTION 15 - GLOSSARY

SECTION 15 - GLOSSARY

What This Section Includes: ■ Definitions of terms used throughout this SPD.

Many of the terms used throughout this SPD may be unfamiliar to you or have a specific meaning with regard to the way the Plan is administered and how Benefits are paid. This section defines terms used throughout this SPD, but it does not describe the Benefits provided by the Plan.

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; or

■ rehabilitative, laboratory, diagnostic or therapeutic services.

An Alternate Facility may also provide Mental Health or Substance-Related and Addictive Disorder Services on an outpatient basis or inpatient basis (for example a Residential Treatment Facility).

Amendment – any attached written description of additional or alternative provisions to the Plan. Amendments are subject to all conditions, limitations and exclusions of the Plan, except for those that the amendment is specifically changing.

Assisted Reproductive Technology (ART) – the comprehensive term for procedures involving the manipulation of human reproductive materials (such as sperm, eggs, and/or embryos) to achieve Pregnancy. Examples of such procedures are:

■ In vitro fertilization (IVF).

■ Gamete intrafallopian transfer (GIFT).

■ Pronuclear stage tubal transfer (PROST).

■ Tubal embryo transfer (TET).

■ Zygote intrafallopian transfer (ZIFT).

Autism Spectrum Disorders – a condition marked by enduring problems communicating and interacting with others, along with restricted and repetitive behavior, interests or activities.

Bariatric Resource Services (BRS) – a program administered by UnitedHealthcare or its affiliates made available to you by CVS Caremark. The BRS program provides:

■ specialized clinical consulting services to Employees and enrolled Dependents to educate on obesity treatment options; and

■ access to specialized Network facilities and Physicians for obesity surgery services.



Benefits – Plan payments for Covered Health Services, subject to the terms and conditions of the plan and any Addendums and/or Amendments.

Body Mass Index (BMI) – a calculation used in obesity risk assessment which uses a person's weight and height to approximate body fat.

BMI – see Body Mass Index (BMI).

Cancer Resource Services (CRS) – a program administered by UnitedHealthcare or its affiliates made available to you by CVS. The CRS program provides:

■ specialized consulting services, on a limited basis, to Employees and enrolled Dependents with cancer;

■ access to cancer centers with expertise in treating the most rare or complex cancers; and

■ education to help patients understand their cancer and make informed decisions about their care and course of treatment.

Certificate of Creditable Coverage - A document furnished by a group health plan or a health insurance company that shows the amount of time the individual has had coverage. This document is used to reduce or eliminate the length of time a preexisting condition exclusion applies.

CHD – see Congenital Heart Disease (CHD).

Claims Administrator – UnitedHealthcare (also known as UnitedHealthcare Services, Inc.) and its affiliates, who provide certain claim administration services for the plan.

Clinical Trial – a scientific study designed to identify new health services that improve health outcomes. In a Clinical Trial, two or more treatments are compared to each other and the patient is not allowed to choose which treatment will be received.

COBRA – see Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).

Coinsurance – the percentage of Eligible Expenses you are required to pay for certain Covered Health Services as described in Section 3, How the HSP Works.

Company – CVS Pharmacy, Inc. and its related affiliates that participate in the Health Savings Plan (collectively “CVS”).

Congenital Anomaly – a physical developmental defect that is present at birth and is identified within the first twelve months of birth.

Congenital Heart Disease (CHD) – any structural heart problem or abnormality that has been present since birth. Congenital heart defects may:

■ be passed from a parent to a child (inherited);

■ develop in the fetus of a woman who has an infection or is exposed to radiation or other toxic substances during her Pregnancy; or



■ have no known cause.

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) – a federal law that requires group health plans to offer continued health insurance coverage to certain Employees and their Dependents whose group health coverage has been terminated.

Cosmetic Procedures – procedures or services that change or improve appearance without significantly improving physiological function, as determined by the Claims Administrator. Reshaping a nose with a prominent bump is a good example of a Cosmetic Procedure because appearance would be improved, but there would be no improvement in function like breathing.

Cost-Effective – the least expensive equipment that performs the necessary function. This term applies to Durable Medical Equipment and prosthetic devices.

Covered Health Services – those health services, including services, supplies or pharmaceutical products, which UnitedHealthcare determines to be:

■ Medically Necessary;

■ included in Sections 5 and 6, Medical Plan Highlights and Additional Coverage Details described as a Covered Health Service;

■ provided to a Covered Person who meets the plan's eligibility requirements, as described under Eligibility in Section 2, Eligibility & Enrollment; and

■ not identified in Section 8, Exclusions.

Covered Person – either the Employee or an enrolled Dependent only while enrolled and eligible for Benefits under the Plan. References to "you" and "your" throughout this SPD are references to a Covered Person.

CRS – see Cancer Resource Services (CRS).

Custodial Care – services that do not require special skills or training and that:

■ provide assistance in activities of daily living (including but not limited to feeding, dressing, bathing, ostomy care, incontinence care, checking of routine vital signs, transferring and ambulating);

■ 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; or

■ do not require continued administration by trained medical personnel in order to be delivered safely and effectively.

Deductible – the amount you must pay for Covered Health Services in a Plan Year before the plan will begin paying Benefits in that Plan Year. The Deductible is shown in the first table in Section 5, Medical Plan Highlights.



Dependent – an individual who meets the eligibility requirements specified in the plan, as described under Eligibility in Section 2, Eligibility & Enrollment. A Dependent does not include anyone who is also enrolled as an Employee. No one can be a Dependent of more than one Employee.

Designated Facility – a facility that has entered into an agreement with the Claims Administrator or with an organization contracting on behalf of the plan, to provide Covered Health Services for the treatment of specified diseases or conditions. A Designated Facility may or may not be located within your geographic area.

To be considered a Designated Facility, a facility must meet certain standards of excellence and have a proven track record of treating specific conditions.

Designated Virtual Network Provider - a provider or facility that has entered into an agreement with the Claims Administrator, or with an organization contracting on the Claims Administrator's behalf, to deliver Covered Health Services via interactive audio and video modalities.

DME – see Durable Medical Equipment (DME).

Domiciliary Care – living arrangements designed to meet the needs of people who cannot live independently but do not require Skilled Nursing Facility services.

Durable Medical Equipment (DME) – medical equipment that is all of the following:

■ used to serve a medical purpose with respect to treatment of a Sickness, Injury or their symptoms;

■ not disposable;

■ not of use to a person in the absence of a Sickness, Injury or their symptoms;

■ durable enough to withstand repeated use;

■ not implantable within the body; and

■ appropriate for use, and primarily used, within the home.

Eligible Expenses – charges for Covered Health Services that are provided while the plan is in effect, determined as follows:

For: Eligible Expenses are Based On:

Network Benefits Contracted rates with the Provider.

Non-Network Benefits ■ negotiated rates agreed to by the non-Network Provider and either the Claims Administrator or one of its vendors, affiliates or subcontractors, at the discretion of the Claims Administrator.



For: Eligible Expenses are Based On:

■ one of the following:

- selected data resources which, in the judgment of the Claims Administrator, represent competitive fees in that geographic area;

- fee(s) that are negotiated with the Provider; - non-Network Coinsurance percentage of the billed

charge; or - a fee schedule that the Claims Administrator

develops.

These provisions do not apply if you receive Covered Health Services from a non-Network Provider in an Emergency. In that case, Eligible Expenses are the amounts billed by the provider, unless the Claims Administrator negotiates lower rates.

For certain Covered Health Services, you are required to pay a percentage of Eligible Expenses in the form of Coinsurance.

Eligible Expenses are subject to the Claims Administrator's reimbursement policy guidelines. You may request a copy of the guidelines related to your claim from the Claims Administrator.

Emergency – a serious medical condition or symptom resulting from Injury, Sickness or Mental Illness, or Substance-Related and Addictive Disorder Services which:

■ arises suddenly; and

■ in the judgment of a reasonable person, requires immediate care and treatment, generally received within 24 hours of onset, to avoid jeopardy to life or health.

Emergency Health Services – health care services and supplies necessary for the treatment of an Emergency.

Employee – a full-time Employee of the Company who meets the eligibility requirements specified in the Plan, as described under Eligibility in Section 2, Eligibility & Enrollment. An Employee must live and/or work in the United States.

Employee Retirement Income Security Act of 1974 (ERISA) – the federal legislation that regulates retirement and employee welfare benefit programs maintained by employers and unions.

Employer – CVS Pharmacy, Inc. and its related affiliates that participate in the plan (collectively “CVS”).

EOB – see Explanation of Benefits (EOB).



ERISA – see Employee Retirement Income Security Act of 1974 (ERISA).

Experimental or Investigational Services – medical, surgical, diagnostic, psychiatric, mental health, Substance-Related and Addictive Disorder Services or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications or devices that, at the time UnitedHealthcare makes 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;

■ 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); or

■ the subject of an ongoing Clinical Trial that meets the definition of a Phase I, II or III Clinical Trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight.

Exceptions:

■ Clinical Trials for which Benefits are available as described under Clinical Trials in Section 6, Additional Coverage Details.

■ If you are not a participant in a qualifying Clinical Trial as described under Clinical Trials in Section 6, Additional Coverage Details, and have a Sickness or condition that is likely to cause death within one year of the request for treatment, UnitedHealthcare may, at its discretion, consider an otherwise Experimental or Investigational Service to be a Covered Health Service for that Sickness or condition. Prior to such consideration, UnitedHealthcare must determine that, although unproven, the service has significant potential as an effective treatment for that Sickness or condition.

Explanation of Benefits (EOB) – a statement provided by UnitedHealthcare to you, your Physician, or another health care professional that explains:

■ the Benefits provided (if any);

■ the allowable reimbursement amounts;

■ Deductibles;

■ Coinsurance;

■ any other reductions taken;

■ the net amount paid by the Plan; and

■ the reason(s) why the service or supply was not covered by the plan.



Gender Identity Disorder – a disorder characterized by the following diagnostic criteria:

■ a strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex);

■ persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex;

■ the disturbance is not concurrent with a physical intersex condition; and

■ the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Health Statement(s) – a single, integrated statement that summarizes EOB information by providing detailed content on account balances and claim activity.

Home Health Agency – a program or organization authorized by law to provide health care services in the home.

Hospital – an institution, operated as required by law, which is:

■ primarily engaged in providing health services, on an inpatient basis, for the acute care and treatment of sick or injured individuals. Care is provided through medical, mental health, Substance-Related and Addictive Disorder Services, diagnostic and surgical facilities, by or under the supervision of a staff of Physicians; and

■ 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 Skilled Nursing Facility, convalescent home or similar institution.

Injury – bodily damage other than Sickness, including all related conditions and recurrent symptoms.

Inpatient Rehabilitation Facility – a Hospital (or a special unit of a Hospital that is designated as an Inpatient Rehabilitation Facility) that provides physical therapy, occupational therapy and/or speech therapy on an inpatient basis, as authorized by law.

Inpatient Stay – an uninterrupted confinement, following formal admission to a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility.

Intensive Outpatient Treatment – a structured outpatient Mental Health or Substance-Related and Addictive Disorder Services 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.

Intermediate Care – Mental Health or Substance-Related and Addictive Disorder Services treatment that encompasses the following:

■ care at a Residential Treatment Facility;

■ care at a Partial Hospitalization/Day Treatment program; or



■ care through an Intensive Outpatient Treatment Program.

Lifetime Maximum Benefit – the most the plan will pay for Benefits during the entire period you are enrolled in this plan or any other medical plan offered by CVS. The Lifetime Maximum Benefit is shown in the first table in Section 5, Medical Plan Highlights.

Manipulative Treatment – the therapeutic application of chiropractic and/or 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.

Medicaid – a federal program administered and operated individually by participating state and territorial governments that provides medical benefits to eligible low-income people needing health care. The federal and state governments share the program's costs.

Medically Necessary – healthcare services provided for the purpose of preventing, evaluating, diagnosing or treating a Sickness, Injury, Mental Illness, Substance-Related and Addictive Disorder Services, condition, disease or its symptoms, that are all of the following as determined by UnitedHealthcare or its designee, within UnitedHealthcare's sole discretion. The services must be:

■ in accordance with Generally Accepted Standards of Medical Practice;

■ clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your Sickness, Injury, Mental Illness, Substance-Related and Addictive Disorder Services or its symptoms;

■ not mainly for your convenience or that of your doctor or other health care provider; and

■ not more costly than an alternative drug, service(s) or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your Sickness, Injury, disease or symptoms.

Generally Accepted Standards of Medical Practice are standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, relying primarily on controlled Clinical Trials, or, if not available, observational studies from more than one institution that suggest a causal relationship between the service or treatment and health outcomes.

If no credible scientific evidence is available, then standards that are based on Physician specialty society recommendations or professional standards of care may be considered. UnitedHealthcare reserves 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 UnitedHealthcare's sole discretion.

UnitedHealthcare develops and maintains clinical policies that describe the Generally Accepted Standards of Medical Practice scientific evidence, prevailing medical standards and clinical guidelines supporting its determinations regarding specific services. These clinical policies (as



developed by UnitedHealthcare and revised from time to time), are available to Covered Persons on www.myuhc.com or by calling the 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/Substance-Related and Addictive Disorder Services Treatment – treatment for the following:

■ any diagnosis which is identified in the current edition of the American Psychiatric Association's Diagnostic and Statistical Manual of the American Psychiatric Association, including a psychological and/or physiological dependence on alcohol or psychoactive drugs or medications, regardless of any underlying physical or organic cause; and

■ any diagnosis where the treatment is primarily the use of psychotherapy or other psychotherapeutic methods.

Mental Health/Substance-Related and Addictive Disorder Services Administrator – the organization or individual designated by CVS who provides or arranges Mental Health and Substance-Related and Addictive Disorders Treatment under the plan.

Mental Illness – mental health or psychiatric diagnostic categories listed in the American Psychiatric Association's Diagnostic and Statistical Manual of the American Psychiatric Association, unless they are listed in Section 8, Exclusions.

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 the Claims Administrator or with its affiliate to participate in the 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. The Claims Administrator's affiliates are those entities affiliated with the Claims Administrator through common ownership or control with the Claims Administrator or with the Claims Administrator's 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 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 - description of how Benefits are paid for Covered Health Services provided by Network Provider. Refer to Section 5, Plan Highlights for details about how Network Benefits apply.



Non-Network Benefits - description of how Benefits are paid for Covered Health Services provided by non-Network Providers. Refer to Section 5, Medical Plan Highlights for details about how Non-Network Benefits apply.

Open Enrollment – the period of time, determined by CVS, during which eligible Employees may enroll themselves and their Dependents under the plan. CVS determines the period of time that is the Open Enrollment period.

Out-of-Pocket Maximum – the maximum amount you pay every Plan Year. Refer to Section 5, Medical Plan Highlights for the Out-of-Pocket Maximum amount. See Section 3, How the HSP Works for a description of how the Out-of-Pocket Maximum works.

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.

Personal Health Support – programs provided by the Claims Administrator that focus on prevention, education, and closing the gaps in care designed to encourage an efficient system of care for you and your covered Dependents.

Personal Health Support Nurse – the primary nurse that UnitedHealthcare may assign to you if you have a chronic or complex health condition. If a Personal Health Support Nurse is assigned to you, this nurse will call you to assess your progress and provide you with information and education.

Physician – any Doctor of Medicine or Doctor of Osteopathy who is properly licensed and qualified by law.

Please note: Any podiatrist, dentist, psychologist, chiropractor, optometrist or other Provider who acts within the scope of his or her license will be considered on the same basis as a Physician. The fact that a Provider is described as a Physician does not mean that Benefits for services from that Provider are available to you under the plan.

Plan Administrator – Executive Vice President and Chief Human Resources Officer of CVS Pharmacy, Inc.

Plan Sponsor – CVS Pharmacy, Inc. (and its participating affiliates).

Pregnancy – includes prenatal care, postnatal care, childbirth, and any complications associated with Pregnancy.

Private Duty Nursing – nursing care that is provided to a patient on a one-to-one basis by licensed nurses in an inpatient or a 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; or



■ 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 a home-care basis, whether the service is skilled or non-skilled independent nursing.

Provider – a health care professional or facility operating as required by law.

Reconstructive Procedure – a procedure performed to address a physical impairment where the expected outcome is restored or improved function. The primary purpose of a Reconstructive Procedure is either to treat a medical condition or to improve or restore physiologic function. Reconstructive Procedures include surgery or other procedures which are associated with an Injury, Sickness or Congenital Anomaly. The primary result of the procedure is not changed or improved physical appearance. The fact that a person may suffer psychologically as a result of the impairment does not classify surgery or any other procedure done to relieve the impairment as a Reconstructive Procedure.

Reproductive Resource Services (RRS) – a program administered by UnitedHealthcare or its affiliates made available to you by CVS. The RRS program provides:

■ Specialized clinical consulting services to Employees and enrolled Dependents to educate on infertility treatment options.

■ Access to specialized Network facilities and Physicians for infertility services.

Residential Treatment Facility – a facility which provides a program of effective Mental Health Services or Substance-Related and Addictive Disorder Services and which meets all of the following requirements:

■ it is established and operated in accordance with applicable state law for residential treatment programs;

■ it provides a program of treatment under the active participation and direction of a Physician and approved by the Mental Health/ Substance-Related and Addictive Disorder Services Administrator;

■ it has or maintains a written, specific and detailed treatment program requiring full-time residence and full-time participation by the patient; and

■ it provides at least the following basic services in a 24-hour per day, structured milieu:

- room and board; - evaluation and diagnosis; - counseling; and - referral and orientation to specialized community resources.

A Residential Treatment Facility that qualifies as a Hospital is considered a Hospital.

Semi-private Room - a room with two or more beds. When an Inpatient Stay in a Semi-private Room is a Covered Health Service, the difference in cost between a Semi-private Room and a private room is a benefit only when a private room is necessary in terms of generally accepted medical practice, or when a Semi-private Room is not available.



Shared Savings Program - the Shared Savings Program provides access to discounts from non-Network Physicians who participate in that program. UnitedHealthcare will use the Shared Savings Program to pay claims when doing so will lower Eligible Expenses. While UnitedHealthcare might negotiate lower Eligible Expenses for Non-Network Benefits, the Coinsurance will stay the same as described in Section 5, Medical Plan Highlights.

UnitedHealthcare does not credential the Shared Savings Program Providers and the Shared Savings Program Providers are not Network Providers. Accordingly, in benefit plans that have both Network and non-Network levels of Benefits, Benefits for Covered Health Services provided by Shared Savings Program Providers will be paid at the non-Network Benefit level (except in situations when Benefits for Covered Health Services provided by non-Network Providers are payable at Network Benefit levels, as in the case of Emergency Health Services). When UnitedHealthcare uses the Shared Savings Program to pay a claim, the patient responsibility is limited to Coinsurance calculated on the contracted rate paid to the Provider, in addition to any required Deductible.

Sickness – physical illness, disease or Pregnancy. The term Sickness as used in this SPD includes Mental Illness and Substance-Related and Addictive Disorder Services, regardless of the cause or origin of the Mental Illness or Substance-Related and Addictive Disorder.

Skilled Care – skilled nursing, teaching, and rehabilitation services when:

■ they are 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;

■ a Physician orders them;

■ they are not delivered for the purpose of assisting with activities of daily living, including, but not limited to, dressing, feeding, bathing or transferring from a bed to a chair;

■ they require clinical training in order to be delivered safely and effectively; and

■ they are not Custodial Care, as defined in this section.

Skilled Nursing Facility – a nursing facility that is licensed and operated as required by law. A Skilled Nursing Facility that is part of a Hospital is considered a Skilled Nursing Facility for purposes of the plan.

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-Related and Addictive Disorder Services, any licensed clinician is considered on the same basis as a Specialist Physician.

Specialty Medications – certain pharmaceutical and/or biotech drugs (including “biosimilars” or “follow-on biologics”) which are used to manage long-term (chronic), rare and complex conditions or genetic disorders, such as rheumatoid arthritis, cancer, multiple sclerosis, growth hormone disorders, immune deficiencies, and more. They include but are not limited to, injectables, infused, inhaled or oral medications, or otherwise require special storage and handling.



Spouse – an individual to whom you are legally married.

Substance-Related and Addictive Disorder Services - Covered Health Services for the diagnosis and treatment of alcoholism and substance-related and addictive disorders that are listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association, unless those services are specifically excluded. The fact that a disorder is listed in the Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment of the disorder is a Covered Health Service.

Transitional Care – Mental Health Services/Substance-Related and Addictive 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, alcohol/drug halfway houses. These are transitional, supervised living arrangements that provide stable and safe housing, an alcohol/drug-free 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; or

■ supervised living arrangement 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.

UnitedHealth Premium Program – a program that identifies network Physicians or facilities that have been designated as a UnitedHealth Premium Program Physician or facility for certain medical conditions.

To be designated as a UnitedHealth Premium Provider, Physicians and facilities must meet program criteria. The fact that a Physician or facility is a Network Physician or facility does not mean that it is a UnitedHealth Premium Program Physician or facility.

Unproven Services – health services, including medications that are not consistent with conclusions of prevailing medical research which demonstrate that the health service has a beneficial effect on health outcomes and that are not based on trials that meet either of the following designs:

■ Well-conducted randomized controlled trials are two or more treatments compared to each other, with the patient not being allowed to choose which treatment is received.

■ Well-conducted cohort studies are studies in which 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.

The Claims Administrator has a process by which it compiles and reviews clinical evidence with respect to certain health services. From time to time, the Claims Administrator issues



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), the Claims Administrator may, at its discretion, consider an otherwise Unproven Service to be a Covered Health Service for that Sickness or condition. Prior to such a consideration, the Claims Administrator 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.

The decision about whether such a service can be deemed a Covered Health Service is solely at the Claims Administrator’s discretion. Other apparently similar promising but unproven services may not qualify.

Urgent Care – treatment of an unexpected Sickness or Injury that is not life-threatening but requires outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering, such as high fever, a skin rash, or an ear infection.

Urgent Care Center – a facility that provides Urgent Care services, as previously defined in this section. In general, Urgent Care Centers:

■ do not require an appointment;

■ are open outside of normal business hours, so you can get medical attention for minor illnesses that occur at night or on weekends; and

■ provide an alternative if you need immediate medical attention, but your Physician cannot see you right away

50174244 (12/2016)

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