6414 - Administrative Servies Only (ASO) for Medical and Pharmacy Benefits, 4.Drawings/ Plans (2)
City of Denton
Gold Medical
Network Only Plan
Effective: January 1, 2017
Group Number: 715130
Summary Plan Description
CITY OF DENTON GOLD MEDICAL PLAN
I TABLE OF CONTENTS
TABLE OF CONTENTS
SECTION 1 - WELCOME ................................................................................................................. 1
SECTION 2 - INTRODUCTION ......................................................................................................... 4
Eligibility ....................................................................................................................................... 4
Cost of Coverage ......................................................................................................................... 4
How to Enroll .............................................................................................................................. 5
When Coverage Begins ............................................................................................................... 5
Changing Your Coverage ............................................................................................................ 5
SECTION 3 - HOW THE PLAN WORKS .......................................................................................... 8
Accessing Benefits ....................................................................................................................... 8
Eligible Expenses ....................................................................................................................... 10
Annual Deductible ..................................................................................................................... 11
Copayment .................................................................................................................................. 11
Coinsurance ................................................................................................................................ 12
Out-of-Pocket Maximum ......................................................................................................... 12
SECTION 4 - CARE COORDINATIONSM and PRIOR AUTHORIZATION ..................................... 14
Care Management ...................................................................................................................... 14
Prior Authorization.................................................................................................................... 15
Covered Health Services which Require Prior Authorization ............................................. 15
Special Note Regarding Medicare ............................................................................................ 16
SECTION 5 - PLAN HIGHLIGHTS ................................................................................................. 17
Payment Terms and Features ................................................................................................... 17
Schedule of Benefits .................................................................................................................. 20
SECTION 6 - ADDITIONAL COVERAGE DETAILS ...................................................................... 28
Ambulance Services ................................................................................................................... 28
Cancer Resource Services (CRS) ............................................................................................. 29
Clinical Trials .............................................................................................................................. 29
Congenital Heart Disease (CHD) Surgeries ........................................................................... 31
Dental Services - Accident Only .............................................................................................. 33
Diabetes Services ....................................................................................................................... 34
CITY OF DENTON GOLD MEDICAL PLAN
II TABLE OF CONTENTS
Durable Medical Equipment (DME) ...................................................................................... 34
Emergency Health Services - Outpatient ............................................................................... 36
Gender Dysphoria ..................................................................................................................... 36
Hearing Aids ............................................................................................................................... 37
Home Health Care ..................................................................................................................... 37
Hospice Care .............................................................................................................................. 38
Hospital - Inpatient Stay ........................................................................................................... 38
Kidney Resource Services (KRS) ............................................................................................. 38
Lab, X-Ray and Diagnostics - Outpatient .............................................................................. 39
Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine
- Outpatient................................................................................................................................. 40
Mental Health Services .............................................................................................................. 40
Neurobiological Disorders - Autism Spectrum Disorder Services ..................................... 41
Nutritional Counseling .............................................................................................................. 42
Obesity Surgery .......................................................................................................................... 42
Ostomy Supplies ........................................................................................................................ 43
Pharmaceutical Products - Outpatient .................................................................................... 43
Physician Fees for Surgical and Medical Services ................................................................. 44
Physician's Office Services - Sickness and Injury .................................................................. 44
Pregnancy - Maternity Services ................................................................................................ 44
Preventive Care Services ........................................................................................................... 45
Prosthetic Devices ..................................................................................................................... 46
Reconstructive Procedures ....................................................................................................... 47
Rehabilitation Services - Outpatient Therapy and Manipulative Treatment ..................... 48
Scopic Procedures - Outpatient Diagnostic and Therapeutic ............................................. 50
Skilled Nursing Facility/Inpatient Rehabilitation Facility Services .................................... 50
Smoking Cessation ..................................................................................................................... 51
Substance-Related and Addictive Disorders Services........................................................... 51
Surgery - Outpatient .................................................................................................................. 52
Temporomandibular Joint (TMJ) Services ............................................................................. 53
Therapeutic Treatments - Outpatient ..................................................................................... 53
Transplantation Services ........................................................................................................... 54
Travel and Lodging .................................................................................................................... 54
CITY OF DENTON GOLD MEDICAL PLAN
III TABLE OF CONTENTS
Urgent Care Center Services .................................................................................................... 55
Virtual Visits ............................................................................................................................... 56
SECTION 7 - RESOURCES TO HELP YOU STAY HEALTHY ...................................................... 57
Consumer Solutions and Self-Service Tools .......................................................................... 57
Disease and Condition Management Services ....................................................................... 60
Wellness Programs ..................................................................................................................... 60
SECTION 8 - EXCLUSIONS AND LIMITATIONS: WHAT THE MEDICAL PLAN WILL NOT
COVER ........................................................................................................................................... 62
Alternative Treatments .............................................................................................................. 62
Dental .......................................................................................................................................... 62
Devices, Appliances and Prosthetics ...................................................................................... 63
Drugs ........................................................................................................................................... 64
Experimental or Investigational or Unproven Services ....................................................... 65
Foot Care .................................................................................................................................... 65
Medical Supplies and Equipment ............................................................................................ 66
Mental Health, Neurobiological Disorders - Autism Spectrum Disorder and Substance-
Related and Addictive Disorders Services .............................................................................. 67
Nutrition ...................................................................................................................................... 67
Personal Care, Comfort or Convenience ............................................................................... 68
Physical Appearance .................................................................................................................. 69
Procedures and Treatments ...................................................................................................... 69
Providers ..................................................................................................................................... 71
Reproduction .............................................................................................................................. 71
Services Provided under Another Plan ................................................................................... 72
Transplants .................................................................................................................................. 72
Travel ........................................................................................................................................... 72
Types of Care ............................................................................................................................. 72
Vision and Hearing .................................................................................................................... 73
All Other Exclusions ................................................................................................................. 74
SECTION 9 - CLAIMS PROCEDURES .......................................................................................... 76
Network Benefits ....................................................................................................................... 76
Non-Network Benefits ............................................................................................................. 76
CITY OF DENTON GOLD MEDICAL PLAN
IV TABLE OF CONTENTS
Prescription Drug Benefit Claims ........................................................................................... 76
If Your Provider Does Not File Your Claim......................................................................... 76
Health Statements ...................................................................................................................... 78
Explanation of Benefits (EOB) ............................................................................................... 78
Claim Denials and Appeals ....................................................................................................... 78
Federal External Review Program ........................................................................................... 80
Limitation of Action .................................................................................................................. 86
SECTION 10 - COORDINATION OF BENEFITS (COB) ................................................................ 87
Determining Which Plan is Primary ....................................................................................... 87
When This Plan is Secondary ................................................................................................... 88
When a Covered Person Qualifies for Medicare ................................................................... 89
Medicare Crossover Program ................................................................................................... 90
Right to Receive and Release Needed Information .............................................................. 91
Overpayment and Underpayment of Benefits ....................................................................... 91
SECTION 11 - SUBROGATION AND REIMBURSEMENT ............................................................ 93
Right of Recovery ...................................................................................................................... 96
SECTION 12 - WHEN COVERAGE ENDS ..................................................................................... 97
Coverage for a Disabled Child ................................................................................................. 98
Extended Coverage for Total Disability ................................................................................. 98
Continuing Coverage Through COBRA ................................................................................ 98
When COBRA Ends ............................................................................................................... 102
Uniformed Services Employment and Reemployment Rights Act .................................. 103
SECTION 13 - OTHER IMPORTANT INFORMATION ................................................................. 104
Qualified Medical Child Support Orders (QMCSOs) ........................................................ 104
Your Relationship with UnitedHealthcare and City of Denton ....................................... 104
Relationship with Providers ................................................................................................... 105
Your Relationship with Providers ......................................................................................... 105
Interpretation of Benefits ....................................................................................................... 106
Information and Records ........................................................................................................ 106
Incentives to Providers ........................................................................................................... 107
Incentives to You ..................................................................................................................... 107
CITY OF DENTON GOLD MEDICAL PLAN
V TABLE OF CONTENTS
Rebates and Other Payments ................................................................................................. 108
Workers' Compensation Not Affected ................................................................................. 108
Future of the Plan .................................................................................................................... 108
Plan Document ........................................................................................................................ 108
SECTION 14 - GLOSSARY .......................................................................................................... 109
SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS .............................................................. 123
Schedule of Benefits ................................................................................................................ 123
Identification Card (ID Card) - Network Pharmacy .......................................................... 126
Benefit Levels ........................................................................................................................... 127
Retail .......................................................................................................................................... 128
Mail Order ................................................................................................................................. 128
Benefits for Preventive Care Medications ............................................................................ 129
Designated Pharmacies ........................................................................................................... 129
Specialty Prescription Drug Products ................................................................................... 129
Assigning Prescription Drug Products to the PDL ............................................................ 130
Prescription Drug Benefit Claims ......................................................................................... 130
Limitation on Selection of Pharmacies ................................................................................. 131
Supply Limits ............................................................................................................................ 131
Prescription Drug Products that are Chemically Equivalent............................................. 131
Special Programs ...................................................................................................................... 131
Prescription Drug Products Prescribed by a Specialist Physician .................................... 131
Rebates and Other Discounts ................................................................................................ 132
Coupons, Incentives and Other Communications ............................................................. 132
Exclusions - What the Prescription Drug Plan Will Not Cover ....................................... 132
Glossary - Outpatient Prescription Drugs ........................................................................... 134
SECTION 16 - IMPORTANT ADMINISTRATIVE INFORMATION: .............................................. 138
ATTACHMENT I - HEALTH CARE REFORM NOTICES ............................................................. 139
Patient Protection and Affordable Care Act ("PPACA") .................................................. 139
ATTACHMENT II - LEGAL NOTICES .......................................................................................... 140
Women's Health and Cancer Rights Act of 1998 ............................................................... 140
Statement of Rights under the Newborns' and Mothers' Health Protection Act .......... 140
CITY OF DENTON GOLD MEDICAL PLAN
VI TABLE OF CONTENTS
ATTACHMENT III – Nondiscrimination and Accessibility Requirements ................................... 1
ATTACHMENT IV – GETTING HELP IN OTHER LANGUAGES OR FORMATS ............................ 1
ADDENDUM - UNITEDHEALTH ALLIES ......................................................................................... 8
Introduction .................................................................................................................................. 8
What is UnitedHealth Allies? ..................................................................................................... 8
Selecting a Discounted Product or Service .............................................................................. 8
Visiting Your Selected Health Care Professional .................................................................... 8
Additional UnitedHealth Allies Information ........................................................................... 9
ADDENDUM - PARENTSTEPS® .................................................................................................... 10
Introduction ................................................................................................................................ 10
What is ParentSteps®? ............................................................................................................... 10
Registering for ParentSteps® .................................................................................................... 10
Selecting a Contracted Provider............................................................................................... 11
Visiting Your Selected Health Care Professional .................................................................. 11
Obtaining a Discount ................................................................................................................ 11
Speaking with a Nurse ............................................................................................................... 11
Additional ParentSteps® Information ..................................................................................... 11
CITY OF DENTON GOLD MEDICAL PLAN
1 SECTION 1 - WELCOME
SECTION 1 - WELCOME
Quick Reference Box
■ Member services, claim inquiries, Care CoordinationSM and Mental Health/Substance
Use Disorder Administrator: 1-800-241-1659.
■ Claims submittal address: UnitedHealthcare - Claims, P.O. Box 30555, Salt Lake City,
UT 84130-0555.
■ Online assistance: www.myuhc.com.
City of Denton is pleased to provide you with this Summary Plan Description (SPD), which
describes the health Benefits available to you and your covered family members. It includes
summaries of:
■ Who is eligible.
■ Services that are covered, called Covered Health Services.
■ Services that are not covered, called Exclusions and Limitations.
■ How Benefits are paid.
■ Your rights and responsibilities under the Plan.
This SPD is designed to meet your information needs. It supersedes any previous printed or
electronic SPD for this Plan.
IMPORTANT
The healthcare service, supply or Pharmaceutical Product is only a Covered Health
Service if it is Medically Necessary. (See definitions of Medically Necessary and Covered
Health Service in Section 14, Glossary.) The fact that a Physician or other provider has
performed or prescribed a procedure or treatment, or the fact that it may be the only
available treatment for a Sickness, Injury, Mental Illness, substance-related and addictive
disorders, disease or its symptoms does not mean that the procedure or treatment is a
Covered Health Service under the Plan.
City of Denton intends to continue this Plan, but reserves the right, in its sole discretion,
to modify, change, revise, amend or terminate the Plan at any time, for any reason, and
without prior notice subject to any collective bargaining agreements between the
Employer and various unions, if applicable. This SPD is not to be construed as a contract
of or for employment. If there should be an inconsistency between the contents of this
summary and the contents of the Plan, your rights shall be determined under the Plan and
not under this summary.
UnitedHealthcare is 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
CITY OF DENTON GOLD MEDICAL PLAN
2 SECTION 1 - WELCOME
ways, it does not guarantee any Benefits. City of Denton is solely responsible for paying
Benefits described in this SPD.
Please read this SPD thoroughly to learn how the Plan works. If you have questions contact
your local Human Resources department or call the number on the back of your ID card.
CITY OF DENTON GOLD MEDICAL PLAN
3 SECTION 1 - WELCOME
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 find copies of your SPD and any future amendments or request printed
copies by contacting Human Resources.
■ Capitalized words in the SPD have special meanings and are defined in Section 14,
Glossary.
■ If eligible for coverage, the words "you" and "your" refer to Covered Persons as
defined in Section 14, Glossary.
■ City of Denton 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.
CITY OF DENTON GOLD MEDICAL PLAN
4 SECTION 2 - INTRODUCTION
SECTION 2 - INTRODUCTION
What this section includes:
■ Who's eligible for coverage under the Plan.
■ The factors that impact your cost for coverage.
■ Instructions and timeframes for enrolling yourself and your eligible Dependents.
■ When coverage begins.
■ When you can make coverage changes under the Plan.
Eligibility
You are eligible to enroll in the Plan if you are a regular full-time employee who is scheduled
to work at least 30 hours per week.
Your eligible Dependents may also participate in the Plan. An eligible Dependent is
considered to be:
■ Your Spouse, as defined in Section 14, Glossary.
■ Your or your Spouse's child who is under age 26, including a natural child, stepchild, a
legally adopted child, a child placed for adoption or a child for whom you or your
Spouse are the legal guardian.
■ An unmarried child age 26 or over who is or becomes disabled and dependent upon you.
Newborns must be added to the plan within 30 days of birth for any services to be covered.
To be eligible for coverage under the Plan, a Dependent must reside within the United
States.
Note: Your Dependents may not enroll in the Plan unless you are also enrolled. In addition,
if you and your Spouse are both covered under the Plan, you may each be enrolled as a
Participant or be covered as a Dependent of the other person, but not both. In addition, if
you and your Spouse are both covered under the Plan, only one parent may enroll your child
as a Dependent.
A Dependent also includes a child for whom health care coverage is required through a
Qualified Medical Child Support Order or other court or administrative order, as described
in Section 13, Other Important Information.
Cost of Coverage
You and City of Denton share in the cost of the Plan. Your contribution amount depends
on the Plan you select and the family members you choose to enroll.
Your contributions are deducted from your paychecks on a before-tax basis. Before-tax
dollars come out of your pay before federal income and Social Security taxes are
CITY OF DENTON GOLD MEDICAL PLAN
5 SECTION 2 - INTRODUCTION
withheldand in most states, before state and local taxes are withheld. This gives your
contributions a special tax advantage and lowers the actual cost to you.
Your contributions are subject to review and City of Denton reserves the right to change
your contribution amount from time to time.
You can obtain current contribution rates by calling Human Resources.
How to Enroll
To enroll, call Human Resources within 31 days of the date you first become eligible for
medical Plan coverage. If you do not enroll within 31 days, you will need to wait until the
next annual Open Enrollment to make your benefit elections.
Each year during annual Open Enrollment, you have the opportunity to review and change
your medical election. Any changes you make during Open Enrollment will become effective
the following January 1.
Important
If you wish to change your benefit elections following your marriage, birth, adoption of a
child, placement for adoption of a child or other family status change, you must contact
Human Resources within 31 days of the event. Otherwise, you will need to wait until the
next annual Open Enrollment to change your elections.
When Coverage Begins
Once Human Resources receives your properly completed enrollment, coverage will begin
on the first day of the month following your date of hire. Coverage for your Dependents will
start on the date your coverage begins, provided you have enrolled them in a timely manner.
Coverage for a Spouse or Dependent stepchild that you acquire via marriage becomes
effective the date of your marriage, provided you notify Human Resources within 31 days of
your marriage. Coverage for Dependent children acquired through birth, adoption, or
placement for adoption is effective the date of the family status change, provided you notify
Human Resources within 31 days of the birth, adoption, or placement.
If You Are Hospitalized When Your Coverage Begins
If you are an inpatient in a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation
Facility on the day your coverage begins, the Plan will pay Benefits for Covered Health
Services related to that Inpatient Stay as long as you receive Covered Health Services in
accordance with the terms of the Plan.
You should notify UnitedHealthcare within 48 hours of the day your coverage begins, or as
soon as is reasonably possible.
Changing Your Coverage
You may make coverage changes during the year only if you experience a change in family
status. The change in coverage must be consistent with the change in status (e.g., you cover
CITY OF DENTON GOLD MEDICAL PLAN
6 SECTION 2 - INTRODUCTION
your Spouse following your marriage, your child following an adoption, etc.). The following
are considered family status changes for purposes of the Plan:
■ Your marriage, divorce, legal separation or annulment.
■ The birth, legal adoption, placement for adoption or legal guardianship of a child.
■ A change in your Spouse's employment or involuntary loss of health coverage (other
than coverage under the Medicare or Medicaid programs) under another employer's plan.
■ Loss of coverage due to the exhaustion of another employer's COBRA benefits,
provided you were paying for premiums on a timely basis.
■ Your death or the death of a Dependent.
■ Your Dependent child no longer qualifying as an eligible Dependent.
■ A change in your or your Spouse's position or work schedule that impacts eligibility for
health coverage.
■ Contributions were no longer paid by the employer (this is true even if you or your
eligible Dependent continues to receive coverage under the prior plan and to pay the
amounts previously paid by the employer).
■ You or your eligible Dependent who were enrolled in an HMO no longer live or work in
that HMO's service area and no other benefit option is available to you or your eligible
Dependent.
■ Benefits are no longer offered by the Plan to a class of individuals that include you or
your eligible Dependent.
■ Termination of your or your Dependent's Medicaid or Children's Health Insurance Program
(CHIP) coverage as a result of loss of eligibility (you must contact Human Resources
within 60 days of termination).
■ You or your Dependent become eligible for a premium assistance subsidy under Medicaid
or CHIP (you must contact Human Resources within 60 days of the date of
determination of subsidy eligibility).
■ A strike or lockout involving you or your Spouse.
■ A court or administrative order.
Unless otherwise noted above, if you wish to change your elections, you must contact
Human Resources within 31 days of the change in family status. Otherwise, you will need to
wait until the next annual Open Enrollment.
While some of these changes in status are similar to qualifying events under COBRA, you, or
your eligible Dependent, do not need to elect COBRA continuation coverage to take
advantage of the special enrollment rights listed above. These will also be available to you or
your eligible Dependent if COBRA is elected.
Note: Any child under age 26 who is placed with you for adoption will be eligible for
coverage on the date the child is placed with you, even if the legal adoption is not yet final. If
CITY OF DENTON GOLD MEDICAL PLAN
7 SECTION 2 - INTRODUCTION
you do not legally adopt the child, all medical Plan coverage for the child will end when the
placement ends. No provision will be made for continuing coverage (such as COBRA
coverage) for the child.
Change in Family Status - Example
Jane is married and has two children who qualify as Dependents. At annual Open
Enrollment, she elects not to participate in City of Denton's medical plan, because her
husband, Tom, has family coverage under his employer's medical plan. In June, Tom
loses his job as part of a downsizing. As a result, Tom loses his eligibility for medical
coverage. Due to this family status change, Jane can elect family medical coverage under
City of Denton's medical plan outside of annual Open Enrollment.
CITY OF DENTON GOLD MEDICAL PLAN
8 SECTION 3 - HOW THE PLAN WORKS
SECTION 3 - HOW THE PLAN WORKS
What this section includes:
■ Accessing Benefits.
■ Eligible Expenses.
■ Annual Deductible.
■ Copayment.
■ Coinsurance.
■ Out-of-Pocket Maximum.
Accessing Benefits
As a participant in this Plan, you have the freedom to choose the Network Physician or
health care professional you prefer each time you need to receive Covered Health Services.
You are eligible for Benefits under this Plan when you receive Covered Health Services from
Physicians and other health care professionals who have contracted with UnitedHealthcare
to provide those services. You must see a Network Physician in order to obtain Benefits.
Except as specifically described within the SPD, Benefits are not available for services
provided by a non-Network provider. This Plan does not provide a non-Network level of
Benefits.
Benefits apply to Covered Health Services that are provided by a Network Physician or
other Network provider. You are not required to select a Primary Physician in order to
obtain Benefits. In general health care terminology, a Primary Physician may also be referred
to as a Primary Care Physician or PCP.
Designated Network Benefits apply to Covered Health Services that are provided by a
Network Physician or other provider that is identified by UnitedHealthcare as a Designated
Facility or Physician. Only certain Physicians and providers have been identified as a
Designated Facility or Physician. Designated Network Benefits are available only for specific
Covered Health Services as identified in Section 5, Plan Highlights. When Designated
Network Benefits apply, they are included in and subject to the same Annual Deductible and
Out-of-Pocket Maximum requirements as all other Covered Health Services provided by
Network providers.
Depending on the geographic area and the service you receive, you may have access through
our Shared Savings Program to non-Network providers who have agreed to discount their
charges for Covered Health Services. If you receive Covered Health Services from these
providers, the Coinsurance will remain the same as it is when you receive Covered Health
Services from non-Network providers who have not agreed to discount their charges;
however, the total that you owe may be less when you receive Covered Health Services from
Shared Savings Program providers than from other non-Network providers because the
Eligible Expense may be a lesser amount.
CITY OF DENTON GOLD MEDICAL PLAN
9 SECTION 3 - HOW THE PLAN WORKS
You must show your identification card (ID card) every time you request health care services
from a Network provider. If you do not show your ID card, Network providers have no way
of knowing that you are enrolled under the Plan. As a result, they may bill you for the entire
cost of the services you receive.
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 number on your
ID card or log onto www.myuhc.com.
Network providers are independent practitioners and are not employees of City of Denton
or UnitedHealthcare. It is your responsibility to select your provider.
UnitedHealthcare's credentialing process confirms public information about the providers'
licenses and other credentials, but does not assure the quality of the services provided.
Before obtaining services you should always verify the Network status of a provider. A
provider's status may change. You can verify the provider's status by calling
UnitedHealthcare. A directory of providers is available online at www.myuhc.com or by
calling the number on your ID card to request a copy.
It is possible that you might not be able to obtain services from a particular Network
provider. The network of providers is subject to change. Or you might find that a particular
Network provider may not be accepting new patients. If a provider leaves the Network or is
otherwise not available to you, you must choose another Network provider to get Benefits.
If you are currently undergoing a course of treatment utilizing a non-Network Physician or
health care facility, you may be eligible to receive transition of care Benefits. This transition
period is available for specific medical services and for limited periods of time. If you have
questions regarding this transition of care reimbursement policy or would like help
determining whether you are eligible for transition of care Benefits, please contact the
number on your ID card.
Do not assume that a Network provider's agreement includes all Covered Health Services.
Some Network providers contract with UnitedHealthcare to provide only certain Covered
Health Services, but not all Covered Health Services. Some Network providers choose to be
a Network provider for only some of UnitedHealthcare's products. Refer to your provider
directory or contact UnitedHealthcare for assistance.
Health Services from Non-Network Providers
If specific Covered Health Services are not available from a Network provider, you may be
eligible for Benefits when Covered Health Services are received from a non-Network
provider. In this situation, your Network Physician will notify the Claims Administrator, and
if the Claims Administrator confirms that care is not available from a Network provider, the
Claims Administrator will work with you and your Network Physician to coordinate care
through a non-Network provider.
CITY OF DENTON GOLD MEDICAL PLAN
10 SECTION 3 - HOW THE PLAN WORKS
When you receive Covered Health Services through a Network Physician, the Plan will pay
Network Benefits for those Covered Health Services, even if one or more of those Covered
Health Services is received from a non-Network provider.
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.
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 provide and
coordinate all of your future Covered Health Services.
If you don't make a selection within 31 days of the date you are notified, UnitedHealthcare
will select a single Network Physician for you.
In the event that you do not use the selected Network Physician, Benefits will not be paid.
Designated Facilities and Other Providers
If you have a medical condition that UnitedHealthcare believes needs special services,
UnitedHealthcare may direct you to a Designated Facility and/or a Designated Physician
chosen by UnitedHealthcare. If you require certain complex Covered Health Services for
which expertise is limited, UnitedHealthcare may direct you to a Network facility or provider
that is outside your local geographic area. If you are required to travel to obtain such
Covered Health Services from a Designated Facility or Designated Physician,
UnitedHealthcare may reimburse certain travel expenses at UnitedHealthcare's discretion.
In both cases, Benefits will only be paid if your Covered Health Services for that condition
are provided by or arranged by the Designated Facility, Designated Physician or other
provider chosen by UnitedHealthcare.
You or your Network Physician must notify UnitedHealthcare of special service needs (such
as transplants or cancer treatment) that might warrant referral to a Designated Facility
and/or Designated Physician. If you do not notify UnitedHealthcare in advance, and if you
receive services from a non-Network facility (regardless of whether it is a Designated
Facility) or other non-Network provider, Benefits will not be paid.
Eligible Expenses
City of Denton 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.
Eligible Expenses are the amount UnitedHealthcare determines that UnitedHealthcare will
pay for Benefits. For Designated Network Benefits and Network Benefits for Covered
CITY OF DENTON GOLD MEDICAL PLAN
11 SECTION 3 - HOW THE PLAN WORKS
Health Services provided by a Network provider, you are not responsible for any difference
between Eligible Expenses and the amount the provider bills. For Covered Health Services
provided by a non-Network provider (other than services otherwise arranged by
UnitedHealthcare), you will be responsible to the non-Network provider for any amount
billed that is greater than the amount UnitedHealthcare determines to be an Eligible
Expense as described below. Eligible Expenses are determined solely in accordance with
UnitedHealthcare's reimbursement policy guidelines, as described in the SPD.
For Designated Network Benefits and Network Benefits, Eligible Expenses are based
on the following:
■ When Covered Health Services are received from a Designated Network and Network
provider, Eligible Expenses are UnitedHealthcare's contracted fee(s) with that provider.
■ When Covered Health Services are received from a non-Network provider as a result of
an Emergency or as arranged by UnitedHealthcare, Eligible Expenses are billed charges
unless a lower amount is negotiated or authorized by law.
Don't Forget Your ID Card
Remember to show your ID card every time you receive health care services from a
Network provider. If you do not show your ID card, a Network provider has no way of
knowing that you are enrolled under the Plan.
Annual Deductible
The Annual Deductible is the amount of Eligible Expenses you must pay each calendar year
for Covered Health Services before you are eligible to begin receiving Benefits. The amounts
you pay toward your Annual Deductible accumulate over the course of the calendar year.
This Plan includes an Annual Deductible that applies to certain Covered Health Services.
Refer to Section 5, Plan Highlights, for details about the specific Covered Health Services to
which the Annual Deductible applies.
Amounts paid toward the Annual Deductible for Covered Health Services that are subject to
a visit or day limit will also be calculated against that maximum benefit limit. As a result, the
limited benefit will be reduced by the number of days or visits you used toward meeting the
Annual Deductible.
The amount that is applied to the Annual Deductible is calculated on the basis of Eligible
Expenses. The Annual Deductible does not include any amount that exceeds Eligible
Expenses. Details about the way in which Eligible Expenses are determined appear in this
section under the heading Eligible Expenses.
Copayment
A Copayment (Copay) is the amount you pay each time you receive certain Covered Health
Services. The Copay is calculated as a flat dollar amount and is paid at the time of service or
when billed by the provider. When Copayments apply, the amount is listed in Section 5, Plan
Highlights, next to the description for each Covered Health Service.
CITY OF DENTON GOLD MEDICAL PLAN
12 SECTION 3 - HOW THE PLAN WORKS
Please note that for Covered Health Services, you are responsible for paying the lesser of:
■ The applicable Copayment.
■ The Eligible Expense.
Details about the way in which Eligible Expenses are determined appear in this section
under the heading Eligible Expenses.
Copays count toward the Out-of-Pocket Maximum. Copays do not count toward the Annual
Deductible. If the Eligible Expense is less than the Copay, you are only responsible for
paying the Eligible Expense and not the Copay.
Coinsurance
Coinsurance is the amount you pay (calculated as a percentage of Eligible Expenses) each
time you receive certain Covered Health Services.
Details about the way in which Eligible Expenses are determined appear in this section
under the heading Eligible Expenses.
Out-of-Pocket Maximum
The annual Out-of-Pocket Maximum is the most you pay each calendar year for Covered
Health Services. If your eligible out-of-pocket expenses in a calendar year exceed the annual
maximum, the Plan pays 100% of Eligible Expenses for Covered Health Services through
the end of the calendar year.
The Out-of-Pocket Maximum applies to all Covered Health Services under the Plan, as
indicated in the table below, including Covered Health Services provided in Section 15,
Outpatient Prescription Drugs. The Out-of-Pocket Maximum for Designated Network and
Network Benefits includes the amount you pay for outpatient prescription drug products
provided in Section 15, Outpatient Prescription Drugs.
The following table identifies what does and does not apply toward your Out-of-Pocket
Maximum:
Plan Features Applies to the Out-
of-Pocket Maximum?
Copays, even those for Covered Health Services available in
Section 15, Outpatient Prescription Drugs Yes
Payments toward the Annual Deductible or Obesity Surgery
Deductible Yes
Coinsurance Payments, even those for Covered Health Services
available in Section 15, Outpatient Prescription Drugs Yes
Charges for non-Covered Health Services No
CITY OF DENTON GOLD MEDICAL PLAN
13 SECTION 3 - HOW THE PLAN WORKS
Plan Features Applies to the Out-
of-Pocket Maximum?
The amounts of any reductions in Benefits you incur by not
obtaining prior authorization as required No
Ancillary or Therapeutically Equivalent Charges described in
Section 15, Outpatient Prescription Drugs. No
CITY OF DENTON GOLD MEDICAL PLAN
14 SECTION 4 - CARE COORDINATIONSM
SECTION 4 - CARE COORDINATIONSM AND PRIOR AUTHORIZATION
What this section includes:
■ An overview of the Care CoordinationSM program.
■ Covered Health Services which Require Prior Authorization.
Care Management
When you seek prior authorization as required, the Claims Administrator will work with you
to implement the care management process and to provide you with information about
additional services that are available to you, such as disease management programs, health
education, and patient advocacy.
UnitedHealthcare provides a program called Care CoordinationSM designed to encourage
personalized, efficient care for you and your covered Dependents.
Care CoordinationSM 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.
Care CoordinationSM nurses will provide a variety of different services to help you and your
covered family members receive appropriate medical care. Program components are subject
to change without notice. When the Claims Administrator is called as required, they will
work with you to implement the Care CoordinationSM process and to provide you with
information about additional services that are available to you, such as disease management
programs, health education, and patient advocacy. As of the publication of this SPD, the
Care CoordinationSM 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.
■ Inpatient care management - If you are hospitalized, a Care CoordinationSM 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
Care CoordinationSM nurse to confirm that medications, needed equipment, or follow-up
services are in place. The Care CoordinationSM 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 Care CoordinationSM nurse to discuss and
CITY OF DENTON GOLD MEDICAL PLAN
15 SECTION 4 - CARE COORDINATIONSM
share important health care information related to the participant's specific chronic or
complex condition.
If you do not receive a call from a Care CoordinationSM nurse but feel you could benefit
from any of these programs, please call the 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. There are some Benefits, however, for
which you are responsible for obtaining 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 the Claims Administrator 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 the Claims Administrator 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 the Claims
Administrator by calling the number on the back of your ID card.
To obtain prior authorization, call the 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
In most cases, Network providers are responsible for obtaining prior authorization from the
Claims Administrator or contacting Care CoordinationSM before they provide these services
to you. However, you are responsible for obtaining prior authorization from the Claims
Administrator prior to receiving a service for:
■ Ambulance – non-emergent air and ground.
■ Clinical Trials.
■ Congenital heart disease surgeries.
■ Dental services - accident only.
■ Obesity surgery.
CITY OF DENTON GOLD MEDICAL PLAN
16 SECTION 4 - CARE COORDINATIONSM
■ Reconstructive Procedures.
■ Transplants.
Notification is required within one business day of 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.
For prior authorization timeframes see Section 6, Additional Coverage Details. For timeframes
and any reductions in Benefits if you do not get prior authorization from the Mental
Health/Substance Use Disorder Administrator, see Section 6, Additional Coverage Details.
Please note that prior authorization is required even if you have a referral from your
Primary Physician to seek care from another Network Physician.
Contacting UnitedHealthcare or Care CoordinationSM is easy.
Simply call the number on your ID card.
Special Note Regarding Medicare
If you are enrolled in Medicare on a primary basis (Medicare pays before the Plan pays
Benefits) the prior authorization requirements do not apply to you. Since Medicare is the
primary payer, the Plan will pay as secondary payer as described in Section 10, Coordination of
Benefits (COB). You are not required to obtain authorization before receiving Covered Health
Services.
CITY OF DENTON GOLD MEDICAL PLAN
17 SECTION 5 - PLAN HIGHLIGHTS
SECTION 5 - PLAN HIGHLIGHTS
What this section includes:
■ Payment Terms and Features.
■ Schedule of Benefits.
Payment Terms and Features
The table below provides an overview of Copays that apply when you receive certain
Covered Health Services, and outlines the Plan's Annual Deductible and Out-of-Pocket
Maximum.
Plan Features Network Amounts
Copays
In addition to these Copays, you may be
responsible for meeting the Annual
Deductible for the Covered Health
Services described in the chart on the
following pages.
■ Emergency Health Services. $300
■ Physician's Office Services
- Tier 1 Designated Primary
Physician $15
- Non-Tier 1 Designated Primary
Physician $25
- Tier 1 Designated Specialist
Physician $25
- Non-Tier 1 Designated Specialist
Physician $35
■ Rehabilitation Services. $35
■ Urgent Care Center Services. $75
■ Virtual Visits. $15
Copays do not apply toward the Annual
Deductible. Copays apply toward the Out-
of-Pocket Maximum.
CITY OF DENTON GOLD MEDICAL PLAN
18 SECTION 5 - PLAN HIGHLIGHTS
Plan Features Network Amounts
Annual Deductible
■ Individual. $750
■ Family (not to exceed the applicable
Individual amount per Covered
Person). $1,500
Obesity Surgery Deductible
The Obesity Surgery Deductible applies
when you receive Covered Health Services
for obesity surgery. The obesity surgery
deductible does apply to the Out-of-
Pocket. The Annual Deductible does not
apply to these services.
$2,500
Annual Out-of-Pocket Maximum
■ Individual. $3,000
■ Family (not to exceed the applicable
Individual amount per Covered
Person). $6,000
The Annual Deductible applies toward the
Out-of-Pocket Maximum for all Covered
Health Services.
The Annual Out-of-Pocket Maximum
applies to all Covered Health Services
under the Plan, including Covered Health
Services provided in Section 15, Outpatient
Prescription Drugs.
Lifetime Maximum Benefit
There is no dollar limit to the amount the
Plan will pay for essential Benefits during
the entire period you are enrolled in this
Plan.
Unlimited
Generally the following are considered to
be essential benefits under the Patient
Protection and Affordable Care Act:
Ambulatory patient services; emergency
services, hospitalization; maternity and
newborn care, mental health and
substance-related and addictive disorders
CITY OF DENTON GOLD MEDICAL PLAN
19 SECTION 5 - PLAN HIGHLIGHTS
Plan Features Network Amounts
services (including behavioral health
treatment); prescription drug products;
rehabilitative and habilitative services and
devices; laboratory services; preventive and
wellness services and chronic disease
management; and pediatric services,
including oral and vision care.
CITY OF DENTON GOLD MEDICAL PLAN
20 SECTION 5 - PLAN HIGHLIGHTS
Schedule of Benefits
This table provides an overview of the Plan's coverage levels. For detailed descriptions of
your Benefits, refer to Section 6, Additional Coverage Details.
Covered Health Services1
Benefit
(The Amount Payable by the Plan based
on Eligible Expenses)
Network
Ambulance Services Ground and/or Air Ambulance
■ Emergency Ambulance. 90% after you meet the Annual Deductible
■ Non-Emergency Ambulance.
Ground or air ambulance, as the Claims
Administrator determines appropriate.
90% after you meet the Annual Deductible
Cancer Services
Oncology services must be received at a
Designated Facility.
See Cancer Resource Services (CRS) in Section 6,
Additional Coverage Details.
Depending upon where the Covered Health
Service is provided, Benefits will be the
same as those stated under each Covered
Health Service category in this section.
Clinical Trials
Benefits are available when the Covered
Health Services are provided by either
Network or non-Network providers,
however the non-Network provider must
agree to accept the Network level of
reimbursement by signing a network
provider agreement specifically for the
patient enrolling in the trial. (Non-
Network Benefits are not available if the
non-Network provider does not agree to
accept the Network level of
reimbursement.)
Depending upon where the Covered Health
Service is provided, Benefits will be the
same as those stated under each Covered
Health Service category in this section.
Congenital Heart Disease (CHD)
Surgeries
CHD surgeries must be received at a
Designated Facility. 90% after you meet the Annual Deductible
CITY OF DENTON GOLD MEDICAL PLAN
21 SECTION 5 - PLAN HIGHLIGHTS
Covered Health Services1
Benefit
(The Amount Payable by the Plan based
on Eligible Expenses)
Network
Dental Services - Accident Only 90% after you meet the Annual Deductible
Diabetes Services
Diabetes Self-Management and Training/
Diabetic Eye Examinations/Foot Care
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 Items
See Durable Medical Equipment in Section 6,
Additional Coverage Details, for limits.
Depending upon where the Covered Health
Service is provided, Benefits for diabetes
self-management items will be the same as
those stated under Durable Medical Equipment
in this section and in Section 15, Outpatient
Prescription Drugs.
Durable Medical Equipment (DME)
See Section 6, Additional Coverage Details, for
limits.
90% after you meet the Annual Deductible
Emergency Health Services -
Outpatient
Emergency services received at a non-
Network Hospital are covered at the
Network level.
100% after you pay a Copayment of $300
per visit
If you are admitted as an inpatient to a
Hospital directly from the Emergency
room, you will not have to pay this Copay.
The Benefits for an Inpatient Stay in a
Hospital will apply instead.
Gender Dysphoria Depending upon where the Covered Health
Service is provided, Benefits will be the
same as those stated under each Covered
Health Service category in this section and
in Section 15, Outpatient Prescription Drugs.
CITY OF DENTON GOLD MEDICAL PLAN
22 SECTION 5 - PLAN HIGHLIGHTS
Covered Health Services1
Benefit
(The Amount Payable by the Plan based
on Eligible Expenses)
Network
Hearing Aids
See Section 6, Additional Coverage Details, for
limits.
90% after you meet the Annual Deductible
Home Health Care
See Section 6, Additional Coverage Details, for
limits.
90% after you meet the Annual Deductible
Hospice Care
See Section 6, Additional Coverage Details, for
limits.
90% after you meet the Annual Deductible
Hospital - Inpatient Stay 90% after you meet the Annual Deductible
Kidney Services
Kidney services must be received at a
Designated Facility.
See Kidney Resource Services (KRS) in Section 6,
Additional Coverage Details.
Depending upon where the Covered Health
Service is provided, Benefits will be the
same as those stated under each Covered
Health Service category in this section.
Lab, X-Ray and Diagnostics -
Outpatient
■ Lab Testing - Outpatient. 100% (Deductible does not apply for lab
and pathology)
■ X-Ray and Other Diagnostic Testing -
Outpatient. 90% (Deductible does not apply for lab and
pathology)
If the service is provided in a Physician’s
office, additional Copays may apply.
Lab, X-Ray and Major Diagnostics –
CT, PET, MRI, MRA and Nuclear
Medicine - Outpatient
90% after you meet the Annual Deductible
(regardless of place of services)
If the service is provided in a Physician’s
office, additional Copays may apply.
CITY OF DENTON GOLD MEDICAL PLAN
23 SECTION 5 - PLAN HIGHLIGHTS
Covered Health Services1
Benefit
(The Amount Payable by the Plan based
on Eligible Expenses)
Network
Mental Health Services
■ Inpatient. 90% after you meet the Annual Deductible
■ Outpatient. 100% after you pay a Copayment of $25
per visit
Neurobiological Disorders - Autism
Spectrum Disorder Services
■ Inpatient. 90% after you meet the Annual Deductible
■ Outpatient. 100% after you pay a Copayment of $25
per visit
Nutritional Counseling
Tier 1 Premium Designated PCP:
100% after you pay a Copayment of $15
per visit
Non-Tier 1 Premium Designated PCP:
100% after you pay a Copayment of $25
per visit
See Section 6, Additional Coverage Details for
limits.
Tier 1 Premium Designated Specialist:
100% after you pay a Copayment of $25
per visit
Non-Tier 1 Premium Designated
Specialist:
100% after you pay a Copayment of $35
per visit
Obesity Surgery
Bariatric services must be received at a
Designated Facility.
See Section 6, Additional Coverage Details for
limits.
70% after a separate $2,500 deductible.
(Note: the Annual Deductible
does not apply)
Ostomy Supplies 90% after you meet the Annual Deductible
Pharmaceutical Products - Outpatient 90% after you meet the Annual Deductible
All office based injections are payable at
100% after the applicable copay.
CITY OF DENTON GOLD MEDICAL PLAN
24 SECTION 5 - PLAN HIGHLIGHTS
Covered Health Services1
Benefit
(The Amount Payable by the Plan based
on Eligible Expenses)
Network
Physician Fees for Surgical and
Medical Services 90% after you meet the Annual Deductible
Physician's Office Services - Sickness
and Injury
■ Primary Physician. Tier 1 Premium Designated PCP:
100% after you pay a Copayment of $15
per visit
Non-Tier 1 Premium Designated PCP:
100% after you pay a Copayment of $25
per visit
■ Specialist Physician. Tier 1 Premium Designated Specialist:
100% after you pay a Copayment of $25
per visit
Non-Tier 1 Premium Designated
Specialist:
100% after you pay a Copayment of $35
per visit
If you receive services in addition to an
office visit, additional Copays,
Deductibles, or Coinsurances may apply.
Refer to Rehabilitation Therapy - Outpatient
Therapy and Manipulative Treatment for a
description of benefit coverage.
No Copayment applies for allergy
injections, for serum or when a physician
charge is not assessed.
Pregnancy - Maternity Services
A Deductible will not apply for a newborn
child whose length of stay in the Hospital
is the same as the mother's length of stay.
The newborn’s annual deductible will
apply if the newborn is discharged after
the mother.
Benefits will be the same as those stated
under each Covered Health Service
category in this section.
For Covered Health Services provided in
the Physician's Office, a $15 Copayment
will apply only to the initial office visit.
First two sonograms are covered at 100%.
Subsequent sonograms are paid at 90%
CITY OF DENTON GOLD MEDICAL PLAN
25 SECTION 5 - PLAN HIGHLIGHTS
Covered Health Services1
Benefit
(The Amount Payable by the Plan based
on Eligible Expenses)
Network
■ Baby wellness services
Includes all charges associated with the
baby during the initial confinement:
facility, physician, pathology, circumcision.
100%
■ Baby non-wellness services
Non-wellness services for a newborn child
whose length of stay in the hospital
exceeds the mother’s length of stay:
90%
Preventive Care Services
■ Physician Office Services. 100%
■ Lab, X-ray or Other Preventive Tests. 100%
■ Breast Pumps. 100%
Prosthetic Devices
See Section 6, Additional Coverage Details, for
limits.
90% after you meet the Annual Deductible
Reconstructive Procedures Depending upon where the Covered Health
Service is provided, Benefits will be the
same as those stated under each Covered
Health Service category in this section.
Rehabilitation Services - Outpatient
Therapy and Manipulative Treatment
See Section 6, Additional Coverage Details, for
visit limits.
100% after you pay a Copayment of $35
per visit
Scopic Procedures - Outpatient
Diagnostic and Therapeutic 90% after you meet the Annual Deductible
If the service is provided in a Physician’s
office, additional Copays may apply.
Skilled Nursing Facility/Inpatient
Rehabilitation Facility Services
See Section 6, Additional Coverage Details, for
limits.
90% after you meet the Annual Deductible
CITY OF DENTON GOLD MEDICAL PLAN
26 SECTION 5 - PLAN HIGHLIGHTS
Covered Health Services1
Benefit
(The Amount Payable by the Plan based
on Eligible Expenses)
Network
Smoking Cessation
No copayment applies in the physician
office when a physician charge is not
assessed.
Tier 1 Premium Designated PCP:
100% after you pay a Copayment of $15
per visit
Non-Tier 1 Premium Designated PCP:
100% after you pay a Copayment of $25
per visit
See Section 6, Additional Coverage Details, for
limits.
Tier 1 Premium Designated Specialist:
100% after you pay a Copayment of $25
per visit
Non-Tier 1 Premium Designated
Specialist:
100% after you pay a Copayment of $35
per visit
Substance-Related and Addictive
Disorder Services
■ Inpatient. 90% after you meet the Annual Deductible
■ Outpatient. 100% after you pay a Copayment of $25
per visit
Surgery - Outpatient 90% after you meet the Annual Deductible
If the service is provided in a Physician’s
office, additional Copays may apply.
Temporomandibular Joint (TMJ)
Services
Depending upon where the Covered Health
Service is provided, Benefits will be the
same as those stated under each Covered
Health Service category in this section
Therapeutic Treatments - Outpatient 90% after you meet the Annual Deductible
If the service is provided in a Physician’s
office, additional Copays may apply.
CITY OF DENTON GOLD MEDICAL PLAN
27 SECTION 5 - PLAN HIGHLIGHTS
Covered Health Services1
Benefit
(The Amount Payable by the Plan based
on Eligible Expenses)
Network
Transplantation Services
Transplantation services must be received
at a Designated Facility. The Claims
Administrator does not require that cornea
transplants be performed at a Designated
Facility.
90% after you meet the Annual Deductible
Travel and Lodging
Covered Health Services must be received
at a Designated Facility.
See Section 6, Additional Coverage Details, for
limits.
For patient and companion(s) of patient
undergoing cancer treatment, Congenital
Heart Disease treatment or transplant
procedures
Urgent Care Center Services 100% after you pay a Copayment of $75
per visit
If the service is provided in a Physician’s
office, additional Copays may apply.
Virtual Visits
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.
100% after you pay a Copayment of $15
per visit
1In general, your Network provider must obtain prior authorization from the Claims Administrator
or Care CoordinationSM, as described in Section 4, Care CoordinationSM before you receive certain
Covered Health Services. There are some Network Benefits, however, for which you are responsible
for obtaining prior authorization from the Claims Administrator or Care CoordinationSM. See Section
6, Additional Coverage Details for further information.
CITY OF DENTON GOLD MEDICAL PLAN
28 SECTION 6 - ADDITIONAL COVERAGE DETAILS
SECTION 6 - ADDITIONAL COVERAGE DETAILS
What this section includes:
■ Covered Health Services for which the Plan pays Benefits.
■ Covered Health Services that require you to obtain prior authorization before you
receive them, and any reduction in Benefits that may apply if you do not call to obtain
prior authorization.
This section supplements the second table in Section 5, Plan Highlights.
While the table provides you with Benefit limitations along with Copayment, Coinsurance
and Annual 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 obtain prior authorization
from the Claims Administrator as required. 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 and Limitations.
Ambulance Services
The Plan covers Emergency ambulance services and transportation provided by a licensed
ambulance service to the nearest Hospital that offers Emergency Health Services. See
Section 14, 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.
The Plan also covers non-Emergency transportation provided by a licensed professional
ambulance (either ground or air ambulance, as UnitedHealthcare 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.
■ From an acute facility to a sub-acute setting.
Prior Authorization Requirement
In most cases, the Claims Administrator will initiate and direct non-Emergency
ambulance transportation. If you are requesting non-Emergency ambulance services,
please remember that you must obtain prior authorization as soon as possible prior to
transport.
CITY OF DENTON GOLD MEDICAL PLAN
29 SECTION 6 - ADDITIONAL COVERAGE DETAILS
Cancer Resource Services (CRS)
The Plan pays Benefits for oncology services provided by Designated Facilities participating
in the Cancer Resource Services (CRS) program. Designated Facility is defined in Section 14,
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 the Claims Administrator or Care CoordinationSM.
■ Call CRS at 1-866-936-6002.
■ Visit www.myoptumhealthcomplexmedical.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 - Sickness and Injury.
■ Physician Fees for Surgical and Medical Services.
■ Scopic Procedures - Outpatient Diagnostic and Therapeutic.
■ Therapeutic Treatments - Outpatient.
■ Hospital - Inpatient Stay.
■ Surgery - Outpatient.
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 notification to the Designated Facility provider performing the
services (even if you self refer to a provider in that Network).
Clinical Trials
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.
■ Cardiovascular disease (cardiac/stroke) which is not life threatening, for which, as
UnitedHealthcare determines, a Clinical Trial meets the qualifying Clinical Trial criteria
stated below.
CITY OF DENTON GOLD MEDICAL PLAN
30 SECTION 6 - ADDITIONAL COVERAGE DETAILS
■ Surgical musculoskeletal disorders of the spine, hip and knees, which are not life
threatening, for which, as UnitedHealthcare determines, a Clinical Trial meets the
qualifying Clinical Trial criteria stated below.
■ Other diseases or disorders which are not life threatening for which, as UnitedHealthcare
determines, a Clinical Trial meets the qualifying Clinical Trial criteria stated below.
Benefits include the reasonable and necessary items and services used to prevent, diagnose
and treat complications arising from participation in a qualifying Clinical Trial.
Benefits are available only when the Covered Person is clinically eligible for participation in
the qualifying Clinical Trial as defined by the researcher.
Routine patient care costs for qualifying Clinical Trials include:
■ Covered Health Services for which Benefits are typically provided absent a Clinical Trial.
■ Covered Health Services required solely for the provision of the Experimental or
Investigational Service(s) or item, the clinically appropriate monitoring of the effects of
the service or item, or the prevention of complications.
■ Covered Health Services needed for reasonable and necessary care arising from the
provision of an Experimental or Investigational Service(s) or item.
Routine costs for Clinical Trials do not include:
■ The Experimental or Investigational Service(s) or item. The only exceptions to this are:
- Certain Category B devices.
- Certain promising interventions for patients with terminal illnesses.
- Other items and services that meet specified criteria in accordance with
UnitedHealthcare's medical and drug policies.
■ Items and services provided solely to satisfy data collection and analysis needs and that
are not used in the direct clinical management of the patient.
■ A service that is clearly inconsistent with widely accepted and established standards of
care for a particular diagnosis.
■ Items and services provided by the research sponsors free of charge for any person
enrolled in the trial.
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.
With respect to cardiovascular disease or musculoskeletal disorders of the spine, hip and
knees and other diseases or disorders which are not life-threatening, a qualifying Clinical
Trial is a Phase I, Phase II, or Phase III Clinical Trial that is conducted in relation to the
CITY OF DENTON GOLD MEDICAL PLAN
31 SECTION 6 - ADDITIONAL COVERAGE DETAILS
detection or treatment of such non-life-threatening disease or disorder and which meets any
of the following criteria in the bulleted list below.
■ Federally funded trials. The study or investigation is approved or funded (which may
include funding through in-kind contributions) by one or more of the following:
- National Institutes of Health (NIH). (Includes National Cancer Institute (NCI)).
- Centers for Disease Control and Prevention (CDC).
- Agency for Healthcare Research and Quality (AHRQ).
- Centers for Medicare and Medicaid Services (CMS).
- A cooperative group or center of any of the entities described above or the
Department of Defense (DOD) or the Veterans Administration (VA).
- A qualified non-governmental research entity identified in the guidelines issued by
the National Institutes of Health for center support grants.
- The Department of Veterans Affairs, the Department of Defense or the Department of Energy
as long as the study or investigation has been reviewed and approved through a
system of peer review that is determined by the Secretary of Health and Human Services
to meet both of the following criteria:
♦ Comparable to the system of peer review of studies and investigations used by
the National Institutes of Health.
♦ Ensures unbiased review of the highest scientific standards by qualified
individuals who have no interest in the outcome of the review.
■ The study or investigation is conducted under an investigational new drug application
reviewed by the U.S. Food and Drug Administration.
■ The study or investigation is a drug trial that is exempt from having such an
investigational new drug application.
■ The Clinical Trial must have a written protocol that describes a scientifically sound study
and have been approved by all relevant institutional review boards (IRBs) before
participants are enrolled in the trial. UnitedHealthcare may, at any time, request
documentation about the trial.
■ The subject or purpose of the trial must be the evaluation of an item or service that
meets the definition of a Covered Health Service and is not otherwise excluded under
the Plan.
Prior Authorization Requirement
You must obtain prior authorization from the Claims Administrator as soon as the
possibility of participation in a Clinical Trial arises.
Congenital Heart Disease (CHD) Surgeries
The Plan pays Benefits for Congenital Heart Disease (CHD) surgeries which are ordered by
a Physician. CHD surgical procedures include surgeries to treat conditions such as
coarctation of the aorta, aortic stenosis, tetralogy of fallot, transposition of the great vessels
and hypoplastic left or right heart syndrome.
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UnitedHealthcare has specific guidelines regarding Benefits for CHD services. Contact
UnitedHealthcare at the number on your ID card for information about these guidelines.
The Plan pays Benefits for 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 for Physician services are described under Physician Fees for Surgical
and Medical Services.
Surgery may be performed as open or closed surgical procedures or may be performed
through interventional cardiac catheterization.
Benefits are available for the following CHD services:
■ 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).
■ Approved fetal interventions.
CHD services other than those listed above are excluded from coverage, unless determined
by the Claims Administrator to be proven procedures for the involved diagnoses. Contact
CHD Resource Services at 1-888-936-7246 before receiving care for information about
CHD services. More information is also available at
www.myoptumhealthcomplexmedical.com.
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 - Sickness and Injury.
■ Physician Fees for Surgical and Medical Services.
■ Scopic Procedures - Outpatient Diagnostic and Therapeutic.
■ Therapeutic Treatments - Outpatient.
■ Hospital - Inpatient Stay.
■ Surgery - Outpatient.
To receive Benefits under the CHD program, you must contact CHD Resource Services
at 1-888-936-7246 prior to obtaining Covered Health Services. The Plan will only pay
Benefits under the CHD program if CHD provides the proper notification to the
Designated Facility provider performing the services (even if you self refer to a provider
in that Network).
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33 SECTION 6 - ADDITIONAL COVERAGE DETAILS
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 - Accident Only
Dental services are covered by the Plan when all of the following are true:
■ Treatment is necessary because of accidental damage.
■ Dental services are received from a Doctor of Dental Surgery or a Doctor of Medical
Dentistry.
■ The dental damage is severe enough that initial contact with a Physician or dentist occurs
within 72 hours of the accident. (You may request an extension of this time period
provided that you do so within 60 days of the Injury and if extenuating circumstances
exist due to the severity of the Injury.)
Please note that dental damage that occurs as a result of normal activities of daily living or
extraordinary use of the teeth is not considered having occurred as an accident. Benefits are
not available for repairs to teeth that are damaged as a result of such activities.
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 immunosuppressive (medication used to reduce inflammation and suppress
the immune system).
■ Direct treatment of acute traumatic Injury, cancer or cleft palate.
Dental services for final treatment to repair the damage caused by accidental Injury must be
started within 3 months of the accident, or if not a Covered Person at the time of the
accident, within the first three months of coverage under the Plan, unless extenuating
circumstances exist (such as prolonged hospitalization or the presence of fixation wires from
fracture care) and completed within 12 months of the accident, or if not a Covered Person at
the time of the accident, within the first 12 months of coverage under the Plan.
The Plan pays for treatment of accidental Injury only for:
■ Emergency examination.
■ Necessary diagnostic X-rays.
■ Endodontic (root canal) treatment.
■ Temporary splinting of teeth.
■ Prefabricated post and core.
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34 SECTION 6 - ADDITIONAL COVERAGE DETAILS
■ Simple minimal restorative procedures (fillings).
■ Extractions.
■ Post-traumatic crowns if such are the only clinically acceptable treatment.
■ Replacement of lost teeth due to the Injury by implant, dentures or bridges.
Prior Authorization Requirement
Please remember that you should obtain prior authorization from the Claims
Administrator as soon as possible, but at least five business days before follow-up (post-
Emergency) treatment begins. (You do not have to obtain authorization before the initial
Emergency treatment.) When you obtain prior authorization, we can determine whether
the service is a Covered Health Service.
Diabetes Services
Diabetes Self-Management and Training/Diabetic Eye Examinations/Foot Care
Outpatient self-management training for the treatment of diabetes, education and medical
nutrition therapy services. Diabetes outpatient self-management training, education and
medical nutrition therapy services must be ordered by a Physician and provided by
appropriately licensed or registered healthcare professionals.
Benefits under this section also include medical eye examinations (dilated retinal
examinations) and preventive foot care for Covered Persons with diabetes.
Diabetic Self-Management Items
Insulin pumps and supplies for the management and treatment of diabetes, based upon the
medical needs of the Covered Person. An insulin pump is subject to all the conditions of
coverage stated under Durable Medical Equipment. Benefits for blood glucose monitors,
insulin syringes with needles, blood glucose and urine test strips, ketone test strips and
tablets and lancets and lancet devices are described is Section 15, Outpatient Prescription Drugs.
Benefits for diabetes equipment that meet the definition of Durable Medical Equipment are
subject to the limit stated under Durable Medical Equipment in this section.
Durable Medical Equipment (DME)
The Plan 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.
■ Appropriate for use in the home.
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35 SECTION 6 - ADDITIONAL COVERAGE DETAILS
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.
■ Negative pressure wound therapy pumps (wound vacuums).
■ 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.
■ Shoe or foot orthotics.
■ Braces that stabilize an injured body part, including necessary adjustments to shoes to
accommodate braces. Braces that stabilize an injured body part and braces to treat
curvature of the spine are considered Durable Medical Equipment and are a Covered
Health Service. Braces that straighten or change the shape of a body part are orthotic
devices and are excluded from coverage. Dental braces are also excluded from coverage.
■ Mechanical equipment necessary for the treatment of chronic or acute respiratory failure
(except that air-conditioners, humidifiers, dehumidifiers, air purifiers and filters, and
personal comfort items are excluded from coverage).
The Plan also covers tubings, nasal cannulas, connectors and masks used in connection with
DME.
Benefits also include speech aid devices and tracheo-esophageal voice devices required for
treatment of severe speech impediment or lack of speech directly attributed to Sickness or
Injury. Benefits for the purchase of speech aid devices and tracheo-esophageal voice devices
are available only after completing a required three-month rental period.
Note: DME is different from prosthetic devices - see Prosthetic Devices in this section.
Benefits for speech aid devices and tracheo-esophageal voice devices are limited to the
purchase of one device during the entire period of time a Covered Person is enrolled under
the Plan. Benefits for repair/replacement are limited to once every three years.
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36 SECTION 6 - ADDITIONAL COVERAGE DETAILS
Benefits for shoe or foot orthotics are limited to the purchase of one pair of orthotics per
calendar year.
Benefits are provided for the repair/replacement of a type of Durable Medical Equipment
once every three calendar years.
At UnitedHealthcare's discretion, replacements are covered for damage beyond repair with
normal wear and tear, when repair costs exceed new purchase price, 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.
Emergency Health Services - Outpatient
The Plan's Emergency services Benefit pays for outpatient treatment at a Hospital or
Alternate Facility when required to stabilize a patient or initiate treatment.
If you are admitted as an inpatient to a Hospital directly from the Emergency room, you will
not have to pay the Copay for Emergency Health Services. 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 the Claims Administrator is notified within one business day of the admission or on
the same day of admission if reasonably possible after you are admitted to a non-Network
Hospital. The Claims Administrator may elect to transfer you to a Network Hospital as soon
as it is medically appropriate to do so. 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, Network Benefits will not be provided. Eligible Expenses will be
determined as described under Eligible Expenses in Section 5, Plan Highlights.
Benefits under this section are not available for services to treat a condition that does not
meet the definition of an Emergency.
Gender Dysphoria
Benefits for the non-surgical treatment of Gender Dysphoria limited to the following
services:
Psychotherapy for Gender Dysphoria and associated co-morbid psychiatric diagnoses are
provided as described under Mental Health Services in your SPD.
Cross-sex hormone therapy administered by a medical provider (for example during an
office visit) is provided under Pharmaceutical Products – Outpatient in your SPD.
Cross-sex hormone therapy dispensed from a pharmacy is provided under Section 15,
Outpatient Prescription Drugs.
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37 SECTION 6 - ADDITIONAL COVERAGE DETAILS
Puberty suppressing medication injected or implanted by a medical provider in a clinical
setting.
Laboratory testing to monitor the safety of continuous cross-sex hormone therapy.
Hearing Aids
The Plan pays Benefits for hearing aids required for the correction of a hearing impairment
(a reduction in the ability to perceive sound which may range from slight to complete
deafness). Hearing aids are electronic amplifying devices designed to bring sound more
effectively into the ear. A hearing aid consists of a microphone, amplifier and receiver.
Benefits are available for a hearing aid that is purchased as a result of a written
recommendation by a Physician. Benefits are provided for the hearing aid and for charges
for associated fitting and testing.
Benefits do not include bone anchored hearing aids. Bone anchored hearing aids are a
Covered Health Service for which Benefits are available under the applicable
medical/surgical Covered Health Services categories in this section only for Covered
Persons who have either of the following:
■ Craniofacial anomalies whose abnormal or absent ear canals preclude the use of a
wearable hearing aid.
■ Hearing loss of sufficient severity that it would not be adequately remedied by a wearable
hearing aid.
Benefits are limited to $5,000 per calendar year. Benefits are limited to a single purchase
(including repair/replacement) per hearing impaired ear every three calendar years.
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 14, Glossary.
■ Provided on a part-time, Intermittent Care schedule when Skilled Care is required. Refer
to Section 14, Glossary for the definition of Skilled Care.
The Claims Administrator will determine 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.
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38 SECTION 6 - ADDITIONAL COVERAGE DETAILS
Benefits are limited to 60 visits per calendar year. One visit equals four hours of Skilled Care
services. This visit limit does not include any service which is billed only for the
administration of intravenous infusion.
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.
Benefits are limited to 360 days per Covered Person during the entire period you are covered
under the Plan. Any combination of Network and Non-Network Benefits for bereavement
counseling is limited to 20 visits per loss received within six months.
Hospital - Inpatient Stay
Hospital Benefits are available for:
■ Non-Physician services and supplies received during an Inpatient Stay.
■ Room and board in a Semi-private Room (a room with two or more beds).
■ Physician services for radiologists, anesthesiologists, pathologists and Emergency room
Physicians.
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 other 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 - Outpatient Diagnostic
and Therapeutic, and Therapeutic Treatments - Outpatient, respectively.
Kidney Resource Services (KRS)
The Plan pays Benefits for Comprehensive Kidney Solution (CKS) that covers both chronic
kidney disease and End Stage Renal Disease (ESRD) provided by Designated Facilities
participating in the Kidney Resource Services (KRS) program. Designated Facility is defined
in Section 14, Glossary.
In order to receive Benefits under this program, KRS must provide the proper notification
to the Network provider performing the services. This is true even if you self refer to a
Network provider participating in the program. Notification is required:
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39 SECTION 6 - ADDITIONAL COVERAGE DETAILS
■ Prior to vascular access placement for dialysis.
■ Prior to any ESRD services.
You or a covered Dependent may:
■ Be referred to KRS by the Claims Administrator or Care CoordinationSM.
■ Call KRS at 1-866-561-7518.
To receive Benefits related to ESRD and chronic kidney disease, you are not required to visit
a Designated Facility. If you receive services from a facility that is not a Designated Facility,
the Plan pays Benefits as described under:
■ Physician's Office Services - Sickness and Injury.
■ Physician Fees for Surgical and Medical Services.
■ Scopic Procedures - Outpatient Diagnostic and Therapeutic.
■ Therapeutic Treatments - Outpatient.
■ Hospital - Inpatient Stay.
■ Surgery - Outpatient.
To receive Benefits under the KRS program, you must contact KRS prior to obtaining
Covered Health Services. The Plan will only pay Benefits under the KRS program if KRS
provides the proper notification to the Designated Facility provider performing the
services (even if you self refer to a provider in that Network).
Lab, X-Ray and Diagnostics - Outpatient
Services for Sickness and Injury-related diagnostic purposes, received on an outpatient basis
at a Hospital or Alternate Facility or in a Physician's office include:
■ Lab and radiology/X-ray.
■ Mammography.
Benefits under this section include:
■ The facility charge and the charge for supplies and equipment.
■ Physician services for radiologists, anesthesiologists and pathologists.
Benefits for other Physician services are described 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. CT scans, PET scans, MRI, MRA,
nuclear medicine and major diagnostic services are described under Lab, X-Ray and Major
Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient in this section.
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40 SECTION 6 - ADDITIONAL COVERAGE DETAILS
Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine -
Outpatient
Services for CT scans, PET scans, MRI, MRA, nuclear medicine, and major diagnostic
services received on an outpatient basis at a Hospital or Alternate Facility or in a Physician's
office.
Benefits under this section include:
■ The facility charge and the charge for supplies and equipment.
■ Physician services for radiologists, anesthesiologists and pathologists.
Benefits for other Physician services are described in this section under Physician Fees for
Surgical and Medical Services.
Mental Health Services
Mental Health Services include those received on an inpatient or outpatient basis in a
Hospital and an Alternate Facility or in a provider's office. All services must be provided by
or under the direction of a properly qualified behavioral health provider.
Benefits include the following levels of care:
■ Inpatient treatment.
■ Residential Treatment.
■ Partial Hospitalization/Day Treatment.
■ Intensive Outpatient Treatment.
■ Outpatient treatment.
Services include the following:
■ Diagnostic evaluations, assessment and treatment planning.
■ Treatment and/or procedures.
■ Medication management and other associated treatments.
■ Individual, family and group therapy.
■ Provider-based case management services.
■ Crisis intervention.
The Mental Health/Substance Use Disorder Administrator provides administrative services
for the inpatient treatment.
You are encouraged to contact the Mental Health/Substance Use Disorder Administrator
for referrals to providers and coordination of care.
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41 SECTION 6 - ADDITIONAL COVERAGE DETAILS
Neurobiological Disorders - Autism Spectrum Disorder Services
The Plan pays Benefits for behavioral services for Autism Spectrum Disorder including
Intensive Behavioral Therapies such as Applied Behavior Analysis (ABA) that are the
following:
■ Focused on the treatment of core deficits of Autism Spectrum Disorder.
■ Provided by a Board Certified Applied Behavior Analyst (BCBA) or other qualified
provider under the appropriate supervision.
■ 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 behavioral 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 applicable medical Covered Health
Services categories as described in this section.
Benefits include the following levels of care:
■ Inpatient treatment.
■ Residential Treatment.
■ Partial Hospitalization/Day Treatment.
■ Intensive Outpatient Treatment.
■ Outpatient treatment.
Services include the following:
■ Diagnostic evaluations, assessment and treatment planning.
■ Treatment and/or procedures.
■ Medication management and other associated treatments.
■ Individual, family and group therapy.
■ Provider-based case management services.
■ Crisis intervention.
The Mental Health/Substance-Related and Addictive Disorders Administrator provides
administrative services for the inpatient treatment.
You are encouraged to contact the Mental Health/Substance-Related and Addictive
Disorders Administrator for referrals to providers and coordination of care.
CITY OF DENTON GOLD MEDICAL PLAN
42 SECTION 6 - ADDITIONAL COVERAGE DETAILS
Nutritional Counseling
The Plan will pay for Covered Health Services for medical education services provided in a
Physician's office 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.
■ There exists a knowledge deficit regarding the disease which requires the intervention of
a trained health professional.
Benefits are limited to four individual sessions per lifetime. This limit applies to non-
preventive nutritional counseling services only.
Some examples of such medical conditions include, but are not limited to:
■ Coronary artery disease.
■ Congestive heart failure.
■ Severe obstructive airway disease.
■ Gout (a form of arthritis).
■ Renal failure.
■ Phenylketonuria (a genetic disorder diagnosed at infancy).
■ Hyperlipidemia (excess of fatty substances in the blood).
When nutritional counseling services are billed as a preventive care service, these services
will be paid as described under Preventive Care Services in this section.
Obesity Surgery
The Plan covers surgical treatment of obesity provided by or under the direction of a
Physician provided either of the following is true:
■ You have a minimum Body Mass Index (BMI) of 40.
■ You have a minimum BMI of 35 with complicating co-morbidities (such as sleep apnea
or diabetes) directly related to, or exacerbated by obesity.
In addition to meeting the above criteria, the following must also be true:
■ You have documentation from a Physician of a diagnosis of morbid obesity for a
minimum of five years.
■ You are over the age of 18.
■ You have completed a 6-month Physician supervised weight loss program documented
within the last two years.
■ You have completed a pre-surgical psychological evaluation.
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43 SECTION 6 - ADDITIONAL COVERAGE DETAILS
■ The surgery is performed at a Bariatric Resource Service (BRS) Designated Facility by a
Network surgeon even if there are no BRS Designated Facilities near you.
Benefits are available for obesity surgery services that meet the definition of a Covered
Health Service, as defined in Section 14, Glossary and are not Experimental or
Investigational or Unproven Services.
Benefits are limited to one surgery per lifetime unless there are complications to the covered
surgery.
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 14,
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 1-888-936-
7246.
Prior Authorization Requirement
You must obtain prior authorization from the Claims Administrator six months prior to
surgery. If you fail to obtain prior authorization as required, you will be responsible for
paying all charges and no Benefits will be paid.
Ostomy Supplies
Benefits for ostomy supplies are limited to:
■ Pouches, face plates and belts.
■ Irrigation sleeves, bags and ostomy irrigation catheters.
■ Urinary catheters when needed as a related supply.
■ Skin barriers.
Benefits are not available for deodorants, filters, lubricants, tape, appliance cleaners,
adhesive, adhesive remover, or other items not listed above.
Pharmaceutical Products - Outpatient
The Plan pays for Pharmaceutical Products that are administered on an outpatient basis in a
Hospital, Alternate Facility, Physician's office, or in a Covered Person's home. Examples of
what would be included under this category are antibiotic injections in the Physician's office
or inhaled medication in an Urgent Care Center for treatment of an asthma attack.
Benefits under this section are provided only for Pharmaceutical Products which, due to
their characteristics (as determined by UnitedHealthcare), must typically be administered or
directly supervised by a qualified provider or licensed/certified health professional. Benefits
under this section do not include medications that are typically available by prescription
order or refill at a pharmacy.
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44 SECTION 6 - ADDITIONAL COVERAGE DETAILS
UnitedHealthcare may have certain programs in which you may receive an enhanced or
reduced Benefit based on your actions such as adherence/compliance to medication or
treatment regimens and/or participation in health management programs. You may access
information on these programs through the Internet at www.myuhc.com or by calling the
number on your ID card.
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 - Sickness and Injury
Benefits are paid by the Plan for Covered Health Services provided in a Physician's office for
the diagnosis and treatment of a Sickness or Injury. Benefits are provided under this section
regardless of whether the Physician's office is free-standing, located in a clinic or located in a
Hospital. Benefits under this section include allergy injections and hearing exams in case of
Injury or Sickness.
Covered Health Services include medical education services that are provided in a
Physician's office by appropriately licensed or registered healthcare professionals when both
of the following are true:
■ Education is required for a disease in which patient self-management is an important
component of treatment.
■ There exists a knowledge deficit regarding the disease which requires the intervention of
a trained health professional.
Covered Health Services include genetic counseling. Benefits are available for Genetic
Testing which is determined to be Medically Necessary following genetic counseling when
ordered by the Physician and authorized in advance by UnitedHealthcare.
Second surgical opinion is covered but is not a required service to obtain Benefits.
Benefits for preventive services are described under Preventive Care Services in this section.
If you receive services in addition to an office visit, additional Copays, Deductibles, or
Coinsurances may apply.
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,
postnatal care, delivery, and any related complications.
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45 SECTION 6 - ADDITIONAL COVERAGE DETAILS
The Plan will pay Benefits for an Inpatient Stay of at least:
■ 48 hours for the mother and newborn child following a vaginal delivery.
■ 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 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.
Healthy moms and babies
The Plan provides a special prenatal program to help during Pregnancy. Participation is
voluntary and free of charge. See Section 7, Resources to Help you Stay Healthy, for details.
Preventive Care Services
The Plan pays Benefits for Preventive care services provided on an outpatient basis at a
Physician's office, an Alternate Facility or a Hospital. Preventive care services encompass
medical services that have been demonstrated by clinical evidence to be safe and effective in
either the early detection of disease or in the prevention of disease, have been proven to
have a beneficial effect on health outcomes and include the following as required under
applicable law:
■ Evidence-based items or services that have in effect a rating of "A" or "B" in the current
recommendations of the United States Preventive Services Task Force.
■ Immunizations that have in effect a recommendation from the Advisory Committee on
Immunization Practices of the Centers for Disease Control and Prevention.
■ With respect to infants, children and adolescents, evidence-informed preventive care and
screenings provided for in the comprehensive guidelines supported by the Health
Resources and Services Administration.
■ With respect to women, such additional preventive care and screenings as provided for
in comprehensive guidelines supported by the Health Resources and Services Administration.
Preventive care Benefits defined under the Health Resources and Services Administration (HRSA)
requirement include the cost of renting one breast pump per Pregnancy in conjunction with
childbirth. Breast pumps must be ordered by or provided by a Physician. You can obtain
additional information on how to access Benefits for breast pumps by going to
www.myuhc.com or by calling the number on your ID card. Benefits for breast pumps also
include the cost of purchasing one breast pump per Pregnancy in conjunction with
CITY OF DENTON GOLD MEDICAL PLAN
46 SECTION 6 - ADDITIONAL COVERAGE DETAILS
childbirth. These Benefits are described under Section 5, Plan Highlights, under Covered Health
Services.
If more than one breast pump can meet your needs, Benefits are available only for the most
cost effective pump. UnitedHealthcare will determine the following:
■ Which pump is the most cost effective.
■ Whether the pump should be purchased or rented.
■ Duration of a rental.
■ Timing of an acquisition.
Benefits are only available if breast pumps are obtained from a DME provider or Physician.
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 external prosthetic devices that replace a limb or body part
limited to:
■ Artificial arms, legs, feet and hands.
■ Artificial face, eyes, ears and noses.
■ Breast prosthesis as required by the Women's Health and Cancer Rights Act of 1998. Benefits
include mastectomy bras and lymphedema stockings for the arm.
Benefits under this section are provided only for external prosthetic devices and do not
include any device that is fully implanted into the body.
If more than one prosthetic device can meet your functional needs, Benefits are available
only for the prosthetic device that meets the minimum specifications for your needs. The
device must be ordered or provided either by a Physician, or under a Physician's direction. If
you purchase a prosthetic device that exceeds these minimum specifications, the Plan will
pay only the amount that it would have paid for the prosthetic that meets the minimum
specifications, and you may be responsible for paying any difference in cost.
Benefits are available for repairs and replacement, except that:
■ There are no Benefits for repairs due to misuse, malicious damage or gross neglect.
■ There are no Benefits for replacement due to misuse, malicious damage, gross neglect or
for lost or stolen prosthetic devices.
Benefits are limited to a single purchase of each type of prosthetic device every three
calendar years.
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47 SECTION 6 - ADDITIONAL COVERAGE DETAILS
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 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 14, Glossary.
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.
Prior Authorization Requirement
For Benefits you must obtain prior authorization 5 business days before a scheduled
reconstructive procedure is performed. When you obtain prior authorization, we can
determine whether the service is considered reconstructive or cosmetic. Cosmetic
procedures are always excluded from coverage.
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48 SECTION 6 - ADDITIONAL COVERAGE DETAILS
Rehabilitation Services - Outpatient Therapy and Manipulative Treatment
The Plan provides short-term outpatient rehabilitation services (including habilitative
services) limited to
■ Physical therapy.
■ Occupational therapy.
■ Manipulative Treatment.
■ Speech therapy.
■ Post-cochlear implant aural therapy.
■ Cognitive rehabilitation therapy following a post-traumatic brain Injury or cerebral
vascular accident.
■ Pulmonary rehabilitation.
■ 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. Benefits under this section include
rehabilitation services provided in a Physician's office or on an outpatient basis at a Hospital
or Alternate Facility. Rehabilitative services provided in a Covered Person’s home by a
Home Health Agency are provided as described under Home Health Care. Rehabilitative
services provided in a Covered Person’s home other than by a Home Health Agency are
provided as described under this section.
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.
Habilitative Services
For the purpose of this Benefit, "habilitative services" means Medically Necessary skilled
health care services that help a person keep, learn or improve skills and functioning for daily
living. Habilitative services are skilled when all of the following are true:
■ The services are part of a prescribed plan of treatment or maintenance program that is
Medically Necessary to maintain a Covered Person's current condition or to prevent or
slow further decline.
■ It is ordered by a Physician and provided and administered by a licensed provider.
■ It is not delivered for the purpose of assisting with activities of daily living, including
dressing, feeding, bathing or transferring from a bed to a chair.
■ It requires clinical training in order to be delivered safely and effectively.
■ It is not Custodial Care.
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49 SECTION 6 - ADDITIONAL COVERAGE DETAILS
The Claims Administrator will determine if Benefits are available by reviewing both the
skilled nature of the service and the need for Physician-directed medical management.
Therapies provided for the purpose of general well-being or conditioning in the absence of a
disabling condition are not considered habilitative services. A service will not be determined
to be "skilled" simply because there is not an available caregiver.
Benefits are provided for habilitative services provided for Covered Persons with a disabling
condition when both of the following conditions are met:
■ The treatment is administered by a licensed speech-language pathologist, licensed
audiologist, licensed occupational therapist, licensed physical therapist or Physician.
■ The initial or continued treatment must be proven and not Experimental or
Investigational.
Benefits for habilitative services do not apply to those services that are solely educational in
nature or otherwise paid under state or federal law for purely educational services. Custodial
Care, respite care, day care, therapeutic recreation, vocational training and Residential
Treatment are not habilitative services. A service that does not help the Covered Person to
meet functional goals in a treatment plan within a prescribed time frame is not a habilitative
service.
The Plan may require that a treatment plan be provided, request medical records, clinical
notes, or other necessary data to allow the Plan to substantiate that initial or continued
medical treatment is needed. When the treating provider anticipates that continued treatment
is or will be required to permit the Covered Person to achieve demonstrable progress, the
Plan may request a treatment plan consisting of diagnosis, proposed treatment by type,
frequency, anticipated duration of treatment, the anticipated goals of treatment, and how
frequently the treatment plan will be updated.
Benefits for Durable Medical Equipment and prosthetic devices, when used as a component
of habilitative services, are described under Durable Medical Equipment and Prosthetic Devices.
Other than as described under Habilitative Services above, please note that the Plan will pay
Benefits for speech therapy for the treatment of disorders of speech, language, voice,
communication and auditory processing only when the disorder results from Injury,
Sickness, stroke, cancer, Congenital Anomaly, autism spectrum disorder or is needed
following the placement of a cochlear implant. The Plan will pay Benefits for cognitive
rehabilitation therapy only when Medically Necessary following a post-traumatic brain Injury
or cerebral vascular accident.
Benefits are limited to:
■ 40 visits per calendar year for physical and occupational therapy combined.
■ 20 visits per calendar year for speech therapy.
■ 20 visits per calendar year for pulmonary rehabilitation therapy.
■ 36 visits per calendar year for cardiac rehabilitation therapy.
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50 SECTION 6 - ADDITIONAL COVERAGE DETAILS
■ 20 visits per calendar year for cognitive rehabilitation therapy.
■ 24 visits per calendar year for Manipulative Treatment.
■ 30 visits per calendar year for post-cochlear implant aural therapy.
Scopic Procedures - Outpatient Diagnostic and Therapeutic
The Plan pays for diagnostic and therapeutic scopic procedures and related services received
on an outpatient basis at a Hospital or Alternate Facility.
Diagnostic scopic procedures are those for visualization, biopsy and polyp removal.
Examples of diagnostic scopic procedures include colonoscopy, sigmoidoscopy, and
endoscopy.
Benefits under this section include:
■ The facility charge and the charge for supplies and equipment.
■ Physician services for radiologists, anesthesiologists and pathologists.
When these services are performed in a Physician's office, Benefits are described under
Physician's Office Services - Sickness and Injury in this section. Benefits for other Physician
services are described in this section under Physician Fees for Surgical and Medical Services.
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.
When these services are performed for preventive screening purposes, Benefits are described
in this section under Preventive Care Services.
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:
■ Supplies and non-Physician services received during the Inpatient Stay.
■ Room and board in a Semi-private Room (a room with two or more beds).
■ Physician services for radiologists, anesthesiologists and pathologists.
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.
Benefits for other Physician services are described in this section under Physician Fees for
Surgical and Medical Services.
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51 SECTION 6 - ADDITIONAL COVERAGE DETAILS
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 both of the following are true:
■ The initial confinement in a Skilled Nursing Facility or Inpatient Rehabilitation Facility
was or will be a Cost Effective alternative to an Inpatient Stay in a Hospital.
■ You will receive skilled care services that are not primarily Custodial Care.
Skilled care is skilled nursing, skilled teaching, and skilled rehabilitation services when all of
the following are true:
■ It must be delivered or supervised by licensed technical or professional medical
personnel in order to obtain the specified medical outcome, and provide for the safety of
the patient.
■ It is ordered by a Physician.
■ It is not delivered for the purpose of assisting with activities of daily living, including
dressing, feeding, bathing or transferring from a bed to a chair.
■ It requires clinical training in order to be delivered safely and effectively.
You are expected to improve to a predictable level of recovery. Benefits can be denied or
shortened for Covered Persons who are not progressing in goal-directed rehabilitation
services or if discharge rehabilitation goals have previously been met.
Note: The Plan does not pay Benefits for Custodial Care or Domiciliary Care, even if
ordered by a Physician, as defined in Section 14, Glossary.
Benefits are limited to 60 days per calendar year.
Smoking Cessation
The Plan pays for smoking cessation treatment received on an outpatient basis in a
provider's office or other facility.
Benefits are limited to four visits per calendar year.
Substance-Related and Addictive Disorders Services
Substance-Related and Addictive Disorders Services include those received on an inpatient
or outpatient basis in a Hospital, an Alternate Facility, or in a provider’s office. All services
must be provided by or under the direction of a properly qualified behavioral health
provider.
Benefits include the following levels of care:
■ Inpatient treatment.
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52 SECTION 6 - ADDITIONAL COVERAGE DETAILS
■ Residential Treatment.
■ Partial Hospitalization/Day Treatment.
■ Intensive Outpatient Treatment.
■ Outpatient treatment.
Services include the following:
■ Diagnostic evaluations, assessment and treatment planning.
■ Treatment and/or procedures.
■ Medication management and other associated treatments.
■ Individual, family and group therapy.
■ Provider-based case management services.
■ Crisis intervention.
The Mental Health/Substance-Related and Addictive Disorders Administrator provides
administrative services for the inpatient treatment.
You are encouraged to contact the Mental Health/Substance Use Disorder Administrator
for referrals to providers and coordination of care.
Surgery - Outpatient
The Plan pays for surgery and related services received on an outpatient basis at a Hospital
or Alternate Facility.
Benefits under this section include certain scopic procedures. Examples of surgical scopic
procedures include arthroscopy, laparoscopy, bronchoscopy and hysteroscopy.
Benefits under this section include:
■ The facility charge and the charge for supplies and equipment.
■ Certain surgical scopic procedures (examples of surgical scopic procedures include
arthroscopy, laparoscopy, bronchoscopy, hysteroscopy).
■ Physician services for radiologists, anesthesiologists and pathologists.
Benefits for other Physician services are described in this section under Physician Fees for
Surgical and Medical Services.
When these services are performed in a Physician's office, Benefits are described under
Physician's Office Services - Sickness and Injury in this section.
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53 SECTION 6 - ADDITIONAL COVERAGE DETAILS
Temporomandibular Joint (TMJ) Services
The Plan covers Services for the evaluation and treatment of temporomandibular joint
syndrome (TMJ) and associated muscles.
Diagnosis: Examination, radiographs and applicable imaging studies and consultation.
Non-surgical treatment including clinical examinations, oral appliances (orthotic splints),
arthrocentesis and trigger-point injections.
Benefits are provided for surgical treatment if the following criteria are met:
■ There is clearly demonstrated radiographic evidence of significant joint abnormality.
■ Non-surgical treatment has failed to adequately resolve the symptoms.
■ Pain or dysfunction is moderate or severe.
Benefits for surgical services include arthrocentesis, arthroscopy, arthroplasty, arthrotomy,
open or closed reduction of dislocations.
Benefits for an Inpatient Stay in a Hospital and Hospital-based Physician services are
described in this section under Hospital - Inpatient Stay and Physician Fees for Surgical and Medical
Services, respectively.
Therapeutic Treatments - Outpatient
The Plan pays Benefits for therapeutic treatments received on an outpatient basis at a
Hospital or Alternate Facility or in a Physician's office, including dialysis (both hemodialysis
and peritoneal dialysis), intravenous chemotherapy or other intravenous infusion therapy and
radiation oncology.
Covered Health Services include medical education services that are provided on an
outpatient basis at a Hospital or Alternate Facility by appropriately licensed or registered
healthcare professionals when:
■ Education is required for a disease in which patient self-management is an important
component of treatment.
■ There exists a knowledge deficit regarding the disease which requires the intervention of
a trained health professional.
Benefits under this section include:
■ The facility charge and the charge for related supplies and equipment.
■ Physician services for anesthesiologists, pathologists and radiologists. Benefits for other
Physician services are described in this section under Physician Fees for Surgical and Medical
Services.
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54 SECTION 6 - ADDITIONAL COVERAGE DETAILS
Transplantation Services
Organ and tissue transplants when ordered by a Physician. Benefits are available for
transplants when the transplant meets the definition of a Covered Health Service, and is not
an Experimental or Investigational or Unproven Service.
Examples of transplants for which Benefits are available include bone marrow, heart,
heart/lung, lung, kidney, kidney/pancreas, liver, liver/small bowel, pancreas, small bowel
and cornea.
Benefits are available to the donor and the recipient when the recipient is covered under this
Plan. Donor costs that are directly related to organ removal or procurement are Covered
Health Services for which Benefits are payable through the organ recipient's coverage under
the Plan.
The Claims Administrator has specific guidelines regarding Benefits for transplant services.
Contact the Claims Administrator at the number on your ID card for information about
these guidelines.
Transplantation services including evaluation for transplant, organ procurement and donor
searches and transplantation procedures must be received at a Designated Facility.
Benefits are also available for cornea transplants. You are not required to notify the Claims
Administrator or Care CoordinationSM of a cornea transplant nor is the cornea transplant
required to be performed at a Designated Facility.
Note: The services described under Travel and Lodging are Covered Health Services only in
connection with transplant services received at a Designated Facility.
Prior Authorization Requirement
You must obtain prior authorization from the Claims Administrator as soon as the
possibility of a transplant arises (and before the time a pre-transplantation evaluation is
performed at a transplant center). If you don't obtain prior authorization and if, as a
result, the services are not performed at a Designated Facility, Benefits will not be paid.
Support in the event of serious illness
If you or a covered family member needs an organ or bone marrow transplant,
UnitedHealthcare can put you in touch with quality treatment centers around the country.
Travel and Lodging
The Claims Administrator will assist the patient and family with travel and lodging
arrangements related to:
■ Congenital Heart Disease (CHD).
■ Transplantation services.
■ Cancer-related treatments.
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55 SECTION 6 - ADDITIONAL COVERAGE DETAILS
For travel and lodging services to be covered, the patient must be receiving services at a
Designated Facility.
Travel and Lodging Expenses
The Plan 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.
■ 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.
Travel and lodging expenses are only available if the recipient lives more than 50 miles from
the Designated Facility for BRS, CRS, transplantation or CHD. 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.
■ Mileage reimbursement at the IRS rate for the most direct route between the patient's
home and the Designated Facility.
A combined overall maximum Benefit of $10,000 per Covered Person applies for all travel
and lodging expenses reimbursed under this Plan in connection with all cancer treatments,
transplant procedures and CHD treatments during the entire period that person is covered
under this Plan.
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 Plan provides Benefits for services, including professional services, received at an
Urgent Care Center, as defined in Section 14, Glossary. When Urgent Care services are
provided in a Physician's office, the Plan pays Benefits as described under Physician's Office
Services - Sickness and Injury.
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56 SECTION 6 - ADDITIONAL COVERAGE DETAILS
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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57 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.
■ Disease and Condition Management Services.
■ Wellness Programs.
City of Denton believes in giving you the tools you need to be an educated health care
consumer. To that end, City of Denton 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.
■ 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 City of Denton
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
Health Survey
You and your Spouse are invited to learn more about your health and wellness at
www.myuhc.com and are encouraged to participate in the online health survey. The health
survey is an interactive questionnaire designed to help you identify your healthy habits as
well as potential health risks.
Your health survey is kept confidential. Completing the survey will not impact your Benefits
or eligibility for Benefits in any way.
To find the health survey, log in to www.myuhc.com. After logging in, access your
personalized Health & Wellness page. If you need any assistance with the online survey, please
call the number on the back of your ID card.
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 City of Denton has available to help you improve
CITY OF DENTON GOLD MEDICAL PLAN
58 SECTION 7 - RESOURCES TO HELP YOU STAY HEALTHY
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.
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.
Reminder Programs
To help you stay healthy, UnitedHealthcare may send you and your covered Dependents
reminders to schedule recommended screening exams. Examples of reminders include:
■ Mammograms for women between the ages of 40 and 68.
■ Pediatric and adolescent immunizations.
■ Cervical cancer screenings for women between the ages of 20 and 64.
■ Comprehensive screenings for individuals with diabetes.
■ Influenza/pneumonia immunizations for enrollees age 65 and older.
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59 SECTION 7 - RESOURCES TO HELP YOU STAY HEALTHY
There is no need to enroll in this program. You will receive a reminder automatically if you
have not had a recommended screening exam.
UnitedHealth Premium® Program
To help people make more informed choices about their health care, the UnitedHealth
Premium® program recognizes Network Physicians who meet standards for quality and cost
efficiency. UnitedHealthcare uses evidence-based medicine and national industry guidelines
to evaluate quality. The cost efficiency standards rely on local market benchmarks for the
efficient use of resources in providing care.
For details on the UnitedHealth Premium® Program including how to locate a UnitedHealth
Premium Physician, log onto www.myuhc.com or call the number on your ID card.
www.myuhc.com
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:
■ Receive personalized messages that are posted to your own website.
■ 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.
■ Access all of the content and wellness topics from NurseLineSM including Live Nurse
Chat 24 hours a day, seven days a week.
■ Complete a health risk assessment to identify health habits you can improve, learn about
healthy lifestyle techniques and access health improvement resources.
■ Use the treatment cost estimator to obtain an estimate of the costs of various procedures
in your area.
■ 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 ID card handy. The
enrollment process is quick and easy.
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60 SECTION 7 - RESOURCES TO HELP YOU STAY HEALTHY
Visit www.myuhc.com and:
■ Make real-time inquiries into the status and history of your claims.
■ View eligibility and Plan Benefit information, including Copays and Annual Deductibles.
■ View and print all of your Explanation of Benefits (EOBs) online.
■ Order a new or replacement ID card or print a temporary ID card.
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
HealtheNotesSM
UnitedHealthcare provides a service called HealtheNotesSM to help educate members and
make suggestions regarding your medical care. HealtheNotesSM provides you and your
Physician with suggestions regarding preventive care, testing or medications, potential
interactions with medications you have been prescribed, and certain treatments. In addition,
your HealtheNotesSM report may include health tips and other wellness information.
UnitedHealthcare makes these suggestions through a software program that provides
retrospective, claims-based identification of medical care. Through this process patients are
identified whose care may benefit from suggestions using the established standards of
evidence based medicine as described in Section 14, Glossary under the definition of Covered
Health Services.
If your Physician identifies any concerns after reviewing his or her HealtheNotesSM report,
he or she may contact you if he or she believes it to be appropriate. In addition, you may use
the information in your report to engage your Physician in discussions regarding your health
and the identified suggestions. Any decisions regarding your care, though, are always
between you and your Physician.
If you have questions or would like additional information about this service, please call the
number on the back of your ID card.
Wellness Programs
Healthy Pregnancy Program
If you are pregnant and enrolled in the medical Plan, you can get valuable educational
information and advice by calling the number on your ID card. This program offers:
■ Pregnancy consultation to identify special needs.
■ Written and on-line educational materials and resources.
■ 24-hour access to experienced maternity nurses.
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61 SECTION 7 - RESOURCES TO HELP YOU STAY HEALTHY
■ A phone call from a care coordinator during your Pregnancy, to see how things are
going.
■ A phone call from a care coordinator approximately four weeks postpartum to give you
information on infant care, feeding, nutrition, immunizations and more.
Participation is completely voluntary and without extra charge. To take full advantage of the
program, you are encouraged to enroll within the first 12 weeks of Pregnancy. You can
enroll any time, up to your 34th week. To enroll, call the number on the back of your ID
card.
As a program participant, you can call any time, 24 hours a day, seven days a week, with any
questions or concerns you might have.
CITY OF DENTON GOLD MEDICAL PLAN
62 SECTION 8 - EXCLUSIONS AND LIMITATIONS
SECTION 8 - EXCLUSIONS AND LIMITATIONS: 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 Plan 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, 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, 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 limited 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 and acupuncture.
2. Aromatherapy.
3. Hypnotism.
4. Massage therapy.
5. Rolfing.
6. Art therapy, music therapy, dance therapy, horseback therapy and other forms of
alternative treatment as defined by the National Center for Complementary and Alternative
Medicine (NCCAM) of the National Institutes of Health. This exclusion does not apply to
Manipulative Treatment and non-manipulative osteopathic care for which Benefits are
provided as described in Section 6, Additional Coverage Details.
Dental
1. Dental care (which includes dental X-rays, supplies and appliances and all associated
expenses, including hospitalizations and anesthesia).
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This exclusion does not apply to accident-related dental services for which Benefits are
provided as described under Dental Services - Accident Only 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, limited to:
- Transplant preparation.
- Prior to the initiation of immunosuppressive drugs.
- The direct treatment of acute traumatic Injury, cancer or cleft palate.
Dental care that is required to treat the effects of a medical condition, but that is not
necessary to directly treat the medical condition, is excluded. Examples include treatment
of dental caries resulting from dry mouth after radiation treatment or as a result of
medication.
Endodontics, periodontal surgery and restorative treatment are excluded.
2. Preventive care, diagnosis, treatment of or related to the teeth, jawbones or gums.
Examples include:
- Extractions. This exclusion does not apply to surgical removal of wisdom teeth.
- Restoration and replacement of teeth.
- Medical or surgical treatments of dental conditions.
- Services to improve dental clinical outcomes.
This exclusion does not apply to preventive care for which Benefits are provided under
the United States Preventive Services Task Force requirement or the Health Resources and Services
Administration (HRSA) requirement. This exclusion also does not apply to accident-
related dental services for which Benefits are provided as described under Dental Services -
Accident Only in Section 6, Additional Coverage Details.
3. Dental implants, bone grafts, and other implant-related procedures.
This exclusion does not apply to accident-related dental services for which Benefits are
provided as described under Dental Services - Accident Only in Section 6, Additional Coverage
Details.
4. Dental braces (orthodontics).
5. Treatment of congenitally missing, malpositioned or supernumerary (extra) teeth, even if
part of a Congenital Anomaly.
Devices, Appliances and Prosthetics
1. Devices used specifically as safety items or to affect performance in sports-related
activities.
2. Orthotic appliances and devices that straighten or re-shape a body part, except as
described under Durable Medical Equipment (DME) in Section 6, Additional Coverage Details.
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Examples of excluded orthotic appliances and devices include but are not limited to,
braces that straighten or change the shape of a body part. This exclusion does not
include diabetic footwear which may be covered for a Covered Person with diabetic foot
disease.
3. Cranial banding.
4. The following items are excluded, even if prescribed by a Physician:
- Blood pressure cuff/monitor.
- Enuresis alarm.
- Non-wearable external defibrillator.
- Trusses.
- Ultrasonic nebulizers.
5. Repairs to prosthetic devices due to misuse, malicious damage or gross neglect.
6. Replacement of prosthetic devices due to misuse, malicious damage or gross neglect or
to replace lost or stolen items.
7. Devices and computers to assist in communication and speech except for speech aid
devices and tracheo-esophageal voice devices for which Benefits are provided as
described under Durable Medical Equipment in Section 6, Additional Coverage Details.
8. Oral appliances for snoring.
Drugs
The exclusions listed below apply to the medical portion of the Plan only. Prescription Drug
coverage is excluded under the medical plan because it is a separate benefit. Coverage may
be available under the Prescription Drug portion of the Plan. See Section 15, Outpatient
Prescription Drugs, for coverage details and exclusions.
1. Prescription Drug Products for outpatient use that are filled by a prescription order or
refill.
2. Self-injectable medications. This exclusion does not apply to medications which, due to
their characteristics, (as determined by UnitedHealthcare, must typically be administered
or directly supervised by a qualified provider or licensed/certified health professional in
an outpatient setting).
3. Non-injectable medications given in a Physician's office. This exclusion does not apply
to non-injectable medications that are required in an Emergency and consumed in the
Physician's office.
4. Over-the-counter drugs and treatments.
5. Growth hormone therapy.
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6. New Pharmaceutical Products and/or new dosage forms until the date they are
reviewed.
7. A Pharmaceutical Product that contains (an) active ingredient(s) available in and
therapeutically equivalent (having essentially the same efficacy and adverse effect profile)
to another covered Pharmaceutical Product. Such determinations may be made up to six
times during a calendar year.
8. A Pharmaceutical Product that contains (an) active ingredient(s) which is (are) a
modified version of and therapeutically equivalent (having essentially the same efficacy
and adverse effect profile) to another covered Pharmaceutical Product. Such
determinations may be made up to six times during a calendar year.
9. Benefits for Pharmaceutical Products for the amount dispensed (days' supply or quantity
limit) which exceeds the supply limit.
10. A Pharmaceutical Product with an approved biosimilar or a biosimilar and
therapeutically equivalent (having essentially the same efficacy and adverse effect profile)
to another covered Pharmaceutical Product. For the purpose of this exclusion a
"biosimilar" is a biological Pharmaceutical Product approved based on showing that it is
highly similar to a reference product (a biological Pharmaceutical Product) and has no
clinically meaningful differences in terms of safety and effectiveness from the reference
product. Such determinations may be made up to six times per calendar year.
11. Certain Pharmaceutical Products for which there are therapeutically equivalent (having
essentially the same efficacy and adverse effect profile) alternatives available, unless
otherwise required by law or approved by us. Such determinations may be made up to
six times during a calendar year.
Experimental or Investigational or Unproven Services
1. Experimental or Investigational Services and Unproven Services and all services related
to Experimental or Investigational and Unproven Services are excluded. The fact that an
Experimental or Investigational or Unproven Service, treatment, device or
pharmacological regimen is the only available treatment for a particular condition will
not result in Benefits if the procedure is considered to be Experimental or
Investigational or Unproven in the treatment of that particular condition.
This exclusion does not apply to Covered Health Services provided during a Clinical
Trial for which Benefits are provided as described under Clinical Trials in Section 6,
Additional Coverage Details.
Foot Care
1. Routine foot care, except when needed for severe systemic disease or preventive foot
care for Covered Persons with diabetes for which Benefits are provided as described
under Diabetes Services in Section 6, Additional Coverage Details. Routine foot care services
that are not covered include:
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- Cutting or removal of corns and calluses.
- Nail trimming or cutting.
- 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.
- 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. Treatment of subluxation of the foot.
5. Shoe inserts.
6. Arch supports.
7. Shoes (standard or custom), lifts and wedges.
Medical Supplies and Equipment
1. Prescribed or non-prescribed medical supplies and disposable supplies. Examples:
- Compression stockings, ace bandages, gauze, diabetic strips, and syringes.
- Urinary catheters.
This exclusion does not apply to:
- Ostomy bags and related supplies, including urinary catheters, for which Benefits are
provided as described under Ostomy Supplies in Section 6, Additional Coverage Details.
- Disposable supplies necessary for the effective use of Durable Medical Equipment
for which Benefits are provided as described under Durable Medical Equipment in
Section 6, Additional Coverage Details.
- Diabetic supplies for which Benefits are provided as described under Diabetes Services
in Section 6, Additional Coverage Details.
2. Tubings, nasal cannulas, connectors and masks except when used with Durable Medical
Equipment.
3. The repair and replacement of Durable Medical Equipment when damaged due to
misuse, malicious breakage or gross neglect.
4. The replacement of lost or stolen Durable Medical Equipment.
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5. 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 and Limitations, 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.
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.
7. Methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol),
Cyclazocine, or their equivalents for drug addiction.
8. Transitional Living services.
Nutrition
1. Nutritional or cosmetic therapy using high dose or mega quantities of vitamins, minerals
or elements, and other nutrition based therapy. Examples include supplements,
electrolytes and foods of any kind (including high protein foods and low carbohydrate
foods).
2. Food of any kind. Foods that are not covered include:
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- 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.
- Other dietary and electrolyte supplements.
3. Health education classes unless offered by UnitedHealthcare or its affiliates, including
but not limited to asthma, smoking cessation, and weight control classes.
Personal Care, Comfort or Convenience
1. Television.
2. Telephone.
3. Beauty/barber service.
4. Guest service.
5. Supplies, equipment and similar incidentals for personal comfort. Examples include:
- Air conditioners, air purifiers and filters and dehumidifiers.
- Batteries and battery chargers.
- Breast pumps. This exclusion does not apply to breast pumps for which Benefits are
provided under the Health Resources and Services Administration (HRSA) requirement;
- Car seats.
- Chairs, bath chairs, feeding chairs, toddler chairs, ergonomically correct chairs, chair
lifts and recliners.
- Exercise equipment and treadmills.
- Hot tubs.
- Humidifiers.
- Jacuzzis.
- Medical alert systems.
- Motorized beds, non-Hospital beds, comfort beds and mattresses.
- Music devices.
- Personal computers.
- Pillows.
- Power-operated vehicles.
- Radios.
- Safety equipment.
- Saunas.
- Stair lifts and stair glides.
- Strollers.
- Treadmills.
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- Vehicle modifications such as van lifts.
- Video players.
- Whirlpools.
Physical Appearance
1. Cosmetic Procedures. See the definition in Section 14, Glossary. Examples include:
- Liposuction or removal of fat deposits considered undesirable, including fat
accumulation under the male breast and nipple.
- Pharmacological regimens, nutritional procedures or treatments.
- Scar or tattoo removal or revision procedures (such as salabrasion, chemosurgery
and other such skin abrasion procedures).
- Hair removal or replacement by any means.
- Treatments for skin wrinkles or any treatment to improve the appearance of the skin.
- Treatment for spider veins.
- Skin abrasion procedures performed as a treatment for acne.
- Treatments for hair loss.
- Varicose vein treatment of the lower extremities, when it is considered cosmetic.
2. Replacement of an existing intact breast implant if the earlier breast implant was
performed as a Cosmetic Procedure. Note: Replacement of an existing breast implant is
considered reconstructive if the initial breast implant followed mastectomy. See
Reconstructive Procedures in Section 6, Additional Coverage Details.
3. Physical conditioning programs such as athletic training, body-building, exercise, fitness,
flexibility, health club memberships and programs, spa treatments and diversion or
general motivation.
4. Weight loss programs whether or not they are under medical supervision or for medical
reasons, even if for morbid obesity.
5. Wigs and other scalp hair prosthesis regardless of the reason for the hair loss.
6. Treatment of benign gynecomastia (abnormal breast enlargement in males).
Procedures and Treatments
1. Biofeedback.
2. Medical and surgical treatment of snoring, except when provided as a part of treatment
for documented obstructive sleep apnea.
3. Rehabilitation services and Manipulative Treatment to improve general physical
condition that are provided to reduce potential risk factors, where significant therapeutic
improvement is not expected, including routine, long-term or maintenance/preventive
treatment.
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4. Outpatient cognitive rehabilitation therapy except as Medically Necessary following
traumatic brain Injury or cerebral vascular accident.
5. Speech therapy to treat stuttering, stammering, or other articulation disorders.
6. Speech therapy, except when required for treatment of a speech impediment or speech
dysfunction that results from Injury, Sickness, stroke, cancer, Congenital Anomaly or
Autism Spectrum Disorder as identified under Rehabilitation Services - Outpatient Therapy
and Manipulative Treatment in Section 6, Additional Coverage Details, or is needed following
the placement of a cochlear implant.
7. Excision or elimination of hanging skin on any part of the body. Examples include
plastic surgery procedures called abdominoplasty or abdominal panniculectomy and
brachioplasty.
8. Psychosurgery (lobotomy).
9. Stand-alone multi-disciplinary smoking cessation programs. These are programs that
usually include health care providers specializing in smoking cessation and may include a
psychologist, social worker or other licensed or certified professional. The programs
usually include intensive psychological support, behavior modification techniques and
medications to control cravings.
10. Chelation therapy, except to treat heavy metal poisoning.
11. Physiological modalities and procedures that result in similar or redundant therapeutic
effects when performed on the same body region during the same visit or office
encounter.
12. Sex transformation operations and related services.
13. The following treatments for obesity:
- Non-surgical treatment of obesity, even if for morbid obesity.
- Surgical treatment of obesity unless there is a diagnosis of morbid obesity as
described under Obesity Surgery in Section 6, Additional Coverage Details.
14. Medical and surgical treatment of excessive sweating (hyperhidrosis).
15. The following services for the diagnosis and treatment of temporomandibular joint
syndrome (TMJ): surface electromyography, Doppler analysis, vibration analysis,
computerized mandibular scan or jaw tracking, craniosacral therapy, orthodontics,
occlusal adjustment, and dental restorations.
16. Upper and lower jawbone surgery and jaw alignment. This exclusion does not apply to
reconstructive jaw surgery required for Covered Persons because of a Congenital
Anomaly, acute traumatic Injury, dislocation, tumors, cancer or obstructive sleep apnea;
Orthognathic surgery, except when necessary as a result of facial trauma or cancer.
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17. Breast reduction surgery except as coverage is required by the Women's Health and Cancer
Rights Act of 1998 for which Benefits are described under Reconstructive Procedures in
Section 6, Additional Coverage Details.
Providers
1. Scheduled services not provided by a Network provider.
2. Services performed by a provider who is a family member by birth or marriage, including
your Spouse, brother, sister, parent or child. This includes any service the provider may
perform on himself or herself.
3. Services performed by a provider with your same legal residence.
4. Services ordered or delivered by a Christian Science practitioner.
5. Services performed by an unlicensed provider or a provider who is operating outside of
the scope of his/her license.
6. Services provided at a free-standing or Hospital-based diagnostic facility without an
order written by a Physician or other provider. Services that are self-directed to a free-
standing or Hospital-based diagnostic facility. Services ordered by a Physician or other
provider who is an employee or representative of a free-standing or Hospital-based
diagnostic facility, when that Physician or other provider:
- Has not been actively involved in your medical care prior to ordering the service.
- Is not actively involved in your medical care after the service is received.
This exclusion does not apply to mammography.
Reproduction
1. Health services and associated expenses for infertility treatments, including assisted
reproductive technology, regardless of the reason for the treatment.
This exclusion does not apply to services required to treat or correct underlying causes
of infertility.
2. Surrogate parenting, donor eggs, donor sperm and host uterus.
3. Storage and retrieval of all reproductive materials (examples include eggs, sperm,
testicular tissue and ovarian tissue).
4. The reversal of voluntary sterilization.
5. Services provided by a doula (labor aide); and
6. Parenting, pre-natal or birthing classes.
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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.
4. For treatment of military service-related disabilities when you are legally entitled to other
coverage, and facilities are reasonably available to you.
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.
2. Health services for transplants involving permanent mechanical or animal organs, 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).
3. Transplants that are not performed at a Designated Facility. (This exclusion does not
apply to cornea transplants.)
4. Health services connected with the removal of an organ or tissue from you for purposes
of a transplant to another person. (Donor costs for removal are payable for a transplant
through the organ recipient's Benefits under the Plan.)
Travel
1. Health services provided in a foreign country, unless required as Emergency Health
Services.
2. Travel or transportation expenses, even if ordered by a Physician, except as identified
under Travel and Lodging in Section 6, Additional Coverage Details. Additional travel
expenses related to Covered Health Services received from a Designated Facility or
Designated Physician may be reimbursed at the Plan's discretion. This exclusion does
not apply to ambulance transportation for which Benefits are provided as described
under Ambulance Services in Section 6, Additional Coverage Details.
Types of Care
1. Custodial Care or maintenance care as defined in Section 14, Glossary or maintenance
care.
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73 SECTION 8 - EXCLUSIONS AND LIMITATIONS
2. Domiciliary Care, as defined in Section 14, Glossary.
3. Multi-disciplinary pain management programs provided on an inpatient basis for acute
pain or for exacerbation of chronic pain.
4. Private Duty Nursing.
5. Respite care. This exclusion does not apply to respite care that is part of an integrated
hospice care program of services provided to a terminally ill person by a licensed hospice
care agency for which Benefits are provided as described under Hospice Care in Section 6,
Additional Coverage Details.
6. Rest cures.
7. Services of personal care attendants.
8. Work hardening (individualized treatment programs designed to return a person to work
or to prepare a person for specific work).
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. Purchase cost and associated fitting charges for eyeglasses or contact lenses.
4. Bone anchored hearing aids except when either of the following applies:
- For Covered Persons with craniofacial anomalies whose abnormal or absent ear
canals preclude the use of a wearable hearing aid.
- For Covered Persons with hearing loss of sufficient severity that it would not be
adequately remedied by a wearable hearing aid.
The Plan will not pay for more than one bone anchored hearing aid per Covered Person
who meets the above coverage criteria during the entire period of time the Covered
Person is enrolled in this Plan. In addition, repairs and/or replacement for a bone
anchored hearing aid for Covered Persons who meet the above coverage are not
covered, other than for malfunctions.
5. Eye exercise or vision therapy.
6. 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.
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74 SECTION 8 - EXCLUSIONS AND LIMITATIONS
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.
3. Charges prohibited by federal anti-kickback or self-referral statutes.
4. Diagnostic tests that are:
- Delivered in other than a Physician's office or health care facility.
- Self-administered home diagnostic tests, including but not limited to HIV and
Pregnancy tests.
5. 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.
- That exceed Eligible Expenses or any specified limitation in this SPD.
6. Foreign language and sign language services.
7. Long term (more than 30 days) storage of blood, umbilical cord or other material.
8. Health services and supplies that do not meet the definition of a Covered Health Service
- see the definition in Section 14, Glossary. Covered Health Services are those health
services including services, supplies or Pharmaceutical Products, which the Claims
Administrator determines to be all of the following:
- Medically Necessary.
- Described as a Covered Health Service in this SPD under Section 6, Additional
Coverage Details and in Section 5, Plan Highlights.
- Not otherwise excluded in this SPD under this Section 8, Exclusions and Limitations.
9. 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
CITY OF DENTON GOLD MEDICAL PLAN
75 SECTION 8 - EXCLUSIONS AND LIMITATIONS
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.
10. Physical, psychiatric or psychological exams, testing, vaccinations, immunizations or
treatments when:
- Required solely for purposes of education, sports or camp, travel, career or
employment, insurance, marriage or adoption; or as a result of incarceration.
- Conducted for purposes of medical research. This exclusion does not apply to
Covered Health Services provided during a Clinical Trial for which Benefits are
provided as described under Clinical Trials in Section 6, Additional Coverage Details.
- Related to judicial or administrative proceedings or orders.
- Required to obtain or maintain a license of any type.
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76 SECTION 9 - CLAIMS PROCEDURES
SECTION 9 - CLAIMS PROCEDURES
What this section includes:
■ How Network and non-Network claims work.
■ 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 Copay or 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 Annual Deductible and paying any Copay
or Coinsurance owed to a Network provider at the time of service, or when you receive a bill
from the provider.
Non-Network Benefits
If you receive a bill for Covered Health Services from a non-Network provider as a result of
an Emergency, 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.
Prescription Drug Benefit Claims
If you wish to receive reimbursement for a prescription, you may submit a post-service claim
as described in this section if:
■ You are asked to pay the full cost of the Prescription Drug Product when you fill it and
you believe that the Plan should have paid for it.
■ You pay a Copay and you believe that the amount of the Copay was incorrect.
If a pharmacy (retail or mail order) fails to fill a prescription that you have presented and you
believe that it is a Covered Health Service, you may submit a pre-service request for Benefits
as described in this section.
If Your Provider Does Not File Your Claim
You can obtain a claim form by visiting www.myuhc.com, calling the toll-free number on
your ID card or contacting Human Resources. If you do not have a claim form, simply
attach a brief letter of explanation to the bill, and verify that the bill contains the information
listed below. If any of these items are missing from the bill, you can include them in your
letter:
■ Your name and address.
■ The patient's name, age and relationship to the Participant.
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77 SECTION 9 - CLAIMS PROCEDURES
■ The number as shown on your ID card.
■ The name, address and tax identification number of the provider of the service(s).
■ A diagnosis from the Physician.
■ The date of service.
■ An itemized bill from the provider that includes:
- The Current Procedural Terminology (CPT) codes.
- A description of, and the charge for, each service.
- The date the Sickness or Injury began.
- A statement indicating either that you are, or you are not, enrolled for coverage
under any other health insurance plan or program. If you are enrolled for other
coverage you must include the name and address of the other carrier(s).
Failure to provide all the information listed above may delay any reimbursement that may be
due you.
For medical claims, the above information should be filed with UnitedHealthcare at the
address on your ID card. When filing a claim for outpatient Prescription Drug Product
Benefits, submit your claim to the pharmacy benefit manager claims address noted on your
ID card.
After UnitedHealthcare has processed your claim, you will receive payment for Benefits that
the Plan allows. It is your responsibility to pay the provider the charges you incurred,
including any difference between what you were billed and what the Plan paid.
Payment of Benefits
You may not assign your Benefits under the Plan or any cause of action related to your
Benefits under the Plan to a provider without UnitedHealthcare's consent. When you assign
your Benefits under the Plan to a non-Network provider with UnitedHealthcare's consent,
and the non-Network provider submits a claim for payment, you and the provider represent
and warrant that the Covered Health Services were actually provided and were medically
appropriate.
When UnitedHealthcare has not consented to an assignment, UnitedHealthcare will send the
reimbursement directly to you (the Participant) for you to reimburse the provider upon
receipt of their bill. However, UnitedHealthcare reserves the right, in its discretion, to pay
the provider directly for services rendered to you. When exercising its discretion with respect
to payment, UnitedHealthcare may consider whether you have requested that payment of
your Benefits be made directly to the provider. Under no circumstances will
UnitedHealthcare pay Benefits to anyone other than you or, in its discretion, your Provider.
Direct payment to a provider shall not be deemed to constitute consent by UnitedHealthcare
to an assignment or to waive the consent requirement. When UnitedHealthcare in its
discretion directs payment to a provider, you remain the sole beneficiary of the payment, and
the provider does not thereby become a beneficiary. Accordingly, legally required notices
concerning your Benefits will be directed to you, although UnitedHealthcare may in its
discretion send information concerning the Benefits to the provider as well. If payment to a
provider is made, the Plan reserves the right to offset Benefits to be paid to the provider by
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any amounts that the provider owes the Plan (including amounts owed as a result of the
assignment of other plans’ overpayment recovery rights to the Plan), pursuant to Refund of
Overpayments in Section 10 Coordination of Benefits.
Form of Payment of Benefits
Payment of Benefits under the Plan shall be in cash or cash equivalents, or in the form of
other consideration that UnitedHealthcare in its discretion determines to be adequate. Where
Benefits are payable directly to a provider, such adequate consideration includes the
forgiveness in whole or in part of amounts the provider owes to other plans for which
UnitedHealthcare makes payments, where the Plan has taken an assignment of the other
plans' recovery rights for value.
Health Statements
Each month in which UnitedHealthcare processes at least one claim for you or a covered
Dependent, you will receive a Health Statement in the mail. Health Statements make it easy
for you to manage your family's medical costs by providing claims information in easy-to-
understand terms.
If you would rather track claims for yourself and your covered Dependents online, you may
do so at www.myuhc.com. You may also elect to discontinue receipt of paper Health
Statements by making the appropriate selection on this site.
Explanation of Benefits (EOB)
You may request that UnitedHealthcare send you a paper copy of an Explanation of
Benefits (EOB) after processing the claim. The EOB will let you know if there is any portion
of the claim you need to pay. If any claims are denied in whole or in part, the EOB will
include the reason for the denial or partial payment. 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 14, Glossary, for
the definition of Explanation of Benefits.
Important - Timely Filing of Non-Network Claims
All claim forms for non-Network services must be submitted within 12 months after the
date of service. Otherwise, the Plan will not pay any Benefits for that Eligible Expense, or
Benefits will be reduced, as determined by UnitedHealthcare. This 12-month requirement
does not apply if you are legally incapacitated. If your claim relates to an Inpatient Stay,
the date of service is the date your Inpatient Stay ends.
Claim Denials and Appeals
If Your Claim is Denied
If a claim for Benefits is denied in part or in whole, you may call UnitedHealthcare at the
number on your ID card before requesting a formal appeal. If UnitedHealthcare cannot
resolve the issue to your satisfaction over the phone, you have the right to file a formal
appeal as described below.
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How to Appeal a Denied Claim
If you wish to appeal a denied pre-service request for Benefits, post-service claim or a
rescission of coverage as described below, you or your authorized representative must
submit your appeal in writing within 180 days of receiving the adverse benefit determination.
You do not need to submit urgent care appeals in writing. This communication should
include:
■ The patient's name and ID number as shown on the ID card.
■ The provider's name.
■ The date of medical service.
■ The reason you disagree with the denial.
■ Any documentation or other written information to support your request.
You or your authorized representative may send a written request for an appeal to:
UnitedHealthcare - Appeals
P.O. Box 30432
Salt Lake City, Utah 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.
Types of claims
The timing of the claims appeal process is based on the type of claim you are appealing.
If you wish to appeal a claim, it helps to understand whether it is an:
■ Urgent care request for Benefits.
■ Pre-service request for Benefits.
■ Post-service claim.
■ Concurrent claim.
Review of an Appeal
UnitedHealthcare will conduct a full and fair review of your appeal. The appeal may be
reviewed by:
■ An appropriate individual(s) who did not make the initial benefit determination.
■ A health care professional with appropriate expertise who was not consulted during the
initial benefit determination process.
Once the review is complete, if UnitedHealthcare upholds the denial, you will receive a
written explanation of the reasons and facts relating to the denial.
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Filing a Second Appeal
Your Plan offers two levels of appeal. If you are not satisfied with the first level appeal
decision, you have the right to request a second level appeal from UnitedHealthcare within
60 days from receipt of the first level appeal determination.
Note: Upon written request and free of charge, any Covered Persons may examine
documents relevant to their claim and/or appeals and submit opinions and comments.
UnitedHealthcare will review all claims in accordance with the rules established by the U.S.
Department of Labor.
Federal External Review Program
If, after exhausting your internal appeals, you are not satisfied with the determination made
by UnitedHealthcare, or if UnitedHealthcare fails to respond to your appeal in accordance
with applicable regulations regarding timing, you may be entitled to request an external
review of UnitedHealthcare's determination. The process is available at no charge to you.
If one of the above conditions is met, you may request an external review of adverse benefit
determinations based upon any of the following:
■ Clinical reasons.
■ The exclusions for Experimental or Investigational Service(s) or Unproven Service(s).
■ Rescission of coverage (coverage that was cancelled or discontinued retroactively).
■ As otherwise required by applicable law.
You or your representative may request a standard external review by sending a written
request to the address set out in the determination letter. You or your representative may
request an expedited external review, in urgent situations as detailed below, by calling the
number on your ID card or by sending a written request to the address set out in the
determination letter. A request must be made within four months after the date you received
UnitedHealthcare's decision.
An external review request should include all of the following:
■ A specific request for an external review.
■ The Covered Person's name, address, and insurance ID number.
■ Your designated representative's name and address, when applicable.
■ The service that was denied.
■ Any new, relevant information that was not provided during the internal appeal.
An external review will be performed by an Independent Review Organization (IRO).
UnitedHealthcare has entered into agreements with three or more IROs that have agreed to
perform such reviews. There are two types of external reviews available:
■ A standard external review.
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81 SECTION 9 - CLAIMS PROCEDURES
■ An expedited external review.
Standard External Review
A standard external review is comprised of all of the following:
■ A preliminary review by UnitedHealthcare of the request.
■ A referral of the request by UnitedHealthcare to the IRO.
■ A decision by the IRO.
Within the applicable timeframe after receipt of the request, UnitedHealthcare will complete
a preliminary review to determine whether the individual for whom the request was
submitted meets all of the following:
■ Is or was covered under the Plan at the time the health care service or procedure that is
at issue in the request was provided.
■ Has exhausted the applicable internal appeals process.
■ Has provided all the information and forms required so that UnitedHealthcare may
process the request.
After UnitedHealthcare completes the preliminary review, UnitedHealthcare will issue a
notification in writing to you. If the request is eligible for external review, UnitedHealthcare
will assign an IRO to conduct such review. UnitedHealthcare will assign requests by either
rotating claims assignments among the IROs or by using a random selection process.
The IRO will notify you in writing of the request's eligibility and acceptance for external
review. You may submit in writing to the IRO within ten business days following the date of
receipt of the notice additional information that the IRO will consider when conducting the
external review. The IRO is not required to, but may, accept and consider additional
information submitted by you after ten business days.
UnitedHealthcare will provide to the assigned IRO the documents and information
considered in making UnitedHealthcare's determination. The documents include:
■ All relevant medical records.
■ All other documents relied upon by UnitedHealthcare.
■ All other information or evidence that you or your Physician submitted. If there is any
information or evidence you or your Physician wish to submit that was not previously
provided, you may include this information with your external review request and
UnitedHealthcare will include it with the documents forwarded to the IRO.
In reaching a decision, the IRO will review the claim anew and not be bound by any
decisions or conclusions reached by UnitedHealthcare. The IRO will provide written notice
of its determination (the "Final External Review Decision") within 45 days after it receives
the request for the external review (unless they request additional time and you agree). The
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IRO will deliver the notice of Final External Review Decision to you and UnitedHealthcare,
and it will include the clinical basis for the determination.
Upon receipt of a Final External Review Decision reversing UnitedHealthcare
determination, the Plan will immediately provide coverage or payment for the benefit claim
at issue in accordance with the terms and conditions of the Plan, and any applicable law
regarding plan remedies. If the Final External Review Decision is that payment or referral
will not be made, the Plan will not be obligated to provide Benefits for the health care
service or procedure.
Expedited External Review
An expedited external review is similar to a standard external review. The most significant
difference between the two is that the time periods for completing certain portions of the
review process are much shorter, and in some instances you may file an expedited external
review before completing the internal appeals process.
You may make a written or verbal request for an expedited external review if you receive
either of the following:
■ An adverse benefit determination of a claim or appeal if the adverse benefit
determination involves a medical condition for which the time frame for completion of
an expedited internal appeal would seriously jeopardize the life or health of the
individual or would jeopardize the individual's ability to regain maximum function and
you have filed a request for an expedited internal appeal.
■ A final appeal decision, if the determination involves a medical condition where the
timeframe for completion of a standard external review would seriously jeopardize the
life or health of the individual or would jeopardize the individual's ability to regain
maximum function, or if the final appeal decision concerns an admission, availability of
care, continued stay, or health care service, procedure or product for which the
individual received emergency services, but has not been discharged from a facility.
Immediately upon receipt of the request, UnitedHealthcare will determine whether the
individual meets both of the following:
■ Is or was covered under the Plan at the time the health care service or procedure that is
at issue in the request was provided.
■ Has provided all the information and forms required so that UnitedHealthcare may
process the request.
After UnitedHealthcare completes the review, UnitedHealthcare will immediately send a
notice in writing to you. Upon a determination that a request is eligible for expedited
external review, UnitedHealthcare will assign an IRO in the same manner UnitedHealthcare
utilizes to assign standard external reviews to IROs. UnitedHealthcare will provide all
necessary documents and information considered in making the adverse benefit
determination or final adverse benefit determination to the assigned IRO electronically or by
telephone or facsimile or any other available expeditious method. The IRO, to the extent the
information or documents are available and the IRO considers them appropriate, must
CITY OF DENTON GOLD MEDICAL PLAN
83 SECTION 9 - CLAIMS PROCEDURES
consider the same type of information and documents considered in a standard external
review.
In reaching a decision, the IRO will review the claim anew and not be bound by any
decisions or conclusions reached by UnitedHealthcare. The IRO will provide notice of the
final external review decision for an expedited external review as expeditiously as the
claimant's medical condition or circumstances require, but in no event more than 72 hours
after the IRO receives the request. If the initial notice is not in writing, within 48 hours after
the date of providing the initial notice, the assigned IRO will provide written confirmation of
the decision to you and to UnitedHealthcare.
You may contact UnitedHealthcare at the toll-free number on your ID card for more
information regarding external review rights, or if making a verbal request for an expedited
external review.
Timing of Appeals Determinations
Separate schedules apply to the timing of claims appeals, depending on the type of claim.
There are three types of claims:
■ Urgent care request for Benefits - a request for Benefits provided in connection with
urgent care services.
■ Pre-Service request for Benefits - a request for Benefits which the Plan must approve or
in which you must notify UnitedHealthcare before non-urgent care is provided.
■ Post-Service - a claim for reimbursement of the cost of non-urgent care that has already
been provided.
Please note that the decision is based only on whether or not Benefits are available under the
Plan for the proposed treatment or procedure.
You may have the right to external review through an Independent Review Organization (IRO)
upon the completion of the internal appeal process. Instructions regarding any such rights,
and how to access those rights, will be provided in the Claims Administrator's decision letter
to you.
The tables below describe the time frames which you and UnitedHealthcare are required to
follow.
Urgent Care Request for Benefits*
Type of Request for Benefits or Appeal Timing
If your request for Benefits is incomplete, UnitedHealthcare
must notify you within: 24 hours
You must then provide completed request for Benefits to
UnitedHealthcare within:
48 hours after
receiving notice of
additional information
required
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84 SECTION 9 - CLAIMS PROCEDURES
Urgent Care Request for Benefits*
Type of Request for Benefits or Appeal Timing
UnitedHealthcare must notify you of the benefit
determination within: 72 hours
If UnitedHealthcare denies your request for Benefits, you
must appeal an adverse benefit determination no later than:
180 days after
receiving the adverse
benefit determination
UnitedHealthcare must notify you of the appeal decision
within:
72 hours after
receiving the appeal
*You do not need to submit urgent care appeals in writing. You should call UnitedHealthcare as
soon as possible to appeal an urgent care request for Benefits.
Pre-Service Request for Benefits*
Type of Request for Benefits or Appeal Timing
If your request for Benefits is filed improperly,
UnitedHealthcare must notify you within: 5 days
If your request for Benefits is incomplete, UnitedHealthcare
must notify you within: 15 days
You must then provide completed request for Benefits
information to UnitedHealthcare within: 45 days
UnitedHealthcare must notify you of the benefit determination:
■ if the initial request for Benefits is complete, within: 15 days
■ after receiving the completed request for Benefits (if the
initial request for Benefits is incomplete), within: 15 days
You must appeal an adverse benefit determination no later
than:
180 days after
receiving the adverse
benefit determination
UnitedHealthcare must notify you of the first level appeal
decision within:
15 days after receiving
the first level appeal
You must appeal the first level appeal (file a second level
appeal) within:
60 days after receiving
the first level appeal
decision
UnitedHealthcare must notify you of the second level appeal
decision within:
15 days after receiving
the second level appeal
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85 SECTION 9 - CLAIMS PROCEDURES
*UnitedHealthcare may require a one-time extension for the initial claim determination, of no more
than 15 days, only if more time is needed due to circumstances beyond control of the Plan.
Post-Service Claims
Type of Claim or Appeal Timing
If your claim is incomplete, UnitedHealthcare must notify you
within: 30 days
You must then provide completed claim information to
UnitedHealthcare within: 45 days
UnitedHealthcare must notify you of the benefit determination:
■ if the initial claim is complete, within: 30 days
■ after receiving the completed claim (if the initial claim is
incomplete), within: 30 days
You must appeal an adverse benefit determination no later
than:
180 days after
receiving the adverse
benefit determination
UnitedHealthcare must notify you of the first level appeal
decision within:
30 days after receiving
the first level appeal
You must appeal the first level appeal (file a second level
appeal) within:
60 days after receiving
the first level appeal
decision
UnitedHealthcare must notify you of the second level appeal
decision within:
30 days after receiving
the second level appeal
Concurrent Care Claims
If an on-going course of treatment was previously approved for a specific period of time or
number of treatments, and your request to extend the treatment is an urgent care request for
Benefits as defined above, your request will be decided within 24 hours, provided your
request is made at least 24 hours prior to the end of the approved treatment.
UnitedHealthcare will make a determination on your request for the extended treatment
within 24 hours from receipt of your request.
If your request for extended treatment is not made at least 24 hours prior to the end of the
approved treatment, the request will be treated as an urgent care request for Benefits and
decided according to the timeframes described above. If an on-going course of treatment
was previously approved for a specific period of time or number of treatments, and you
request to extend treatment in a non-urgent circumstance, your request will be considered a
new request and decided according to post-service or pre-service timeframes, whichever
applies.
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86 SECTION 9 - CLAIMS PROCEDURES
Limitation of Action
You cannot bring any legal action against City of Denton or the Claims Administrator to
recover reimbursement until 90 days after you have properly submitted a request for
reimbursement as described in this section and all required reviews of your claim have been
completed. If you want to bring a legal action against City of Denton or the Claims
Administrator, you must do so within three years from the expiration of the time period in
which a request for reimbursement must be submitted or you lose any rights to bring such
an action against City of Denton or the Claims Administrator.
You cannot bring any legal action against City of Denton or the Claims Administrator for
any other reason unless you first complete all the steps in the appeal process described in
this section. After completing that process, if you want to bring a legal action against City of
Denton or the Claims Administrator you must do so 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
against City of Denton or the Claims Administrator.
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SECTION 10 - COORDINATION OF BENEFITS (COB)
What this section includes:
■ How your Benefits under this Plan coordinate with other medical plans.
■ How coverage is affected if you become eligible for Medicare.
■ Procedures in the event the Plan 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.
■ 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. How much
this Plan will reimburse you, if anything, will also depend in part on the allowable expense.
The term, "allowable expense," is further explained below.
Don't forget to update your Dependents' Medical Coverage Information
Avoid delays on your Dependent claims by updating your Dependent's medical coverage
information. Just log on to www.myuhc.com or call the toll-free number on your ID
card to update your COB information. You will need the name of your Dependent's
other medical coverage, along with the policy number.
Determining Which Plan is Primary
Order of Benefit Determination Rules
If you are covered by two or more plans, the benefit payment follows the rules below in this
order:
■ This Plan 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.
CITY OF DENTON GOLD MEDICAL PLAN
88 SECTION 10 - COORDINATION OF BENEFITS (COB)
■ If you are receiving COBRA continuation coverage under another employer plan, this
Plan 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.
- A court decree awards joint custody without specifying that one party has the
responsibility to provide health care coverage.
■ If two or 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.
■ 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, this Plan will not pay more than it would have paid had it been the
primary Plan.
The following examples illustrate how the Plan 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 unwell and go to see a Physician. Since you're covered as a
Participant under this Plan, and as a Dependent under your Spouse's plan, this Plan 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. This Plan 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 this Plan is secondary, it determines the amount it will pay for a Covered Health Service
by following the steps below.
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89 SECTION 10 - COORDINATION OF BENEFITS (COB)
■ The Plan determines the amount it would have paid based on the allowable expense.
■ The Plan pays the entire difference between the allowable expense and the amount paid
by the primary plan - as long as this amount is not more than the Plan would have paid
had it been the only plan involved.
■ If, based on the allowable expense, the Plan would have paid more if it were the only
plan involved, the difference between the amount it would have paid and the amount it
actually paid is recorded as a benefit reserve for the Covered Person. This reserve can be
used to pay any future allowable expenses not otherwise paid by the Plan during the
calendar year.
■ At the end of the calendar year, the benefit reserve returns to zero. A new benefit
reserve is created for each calendar year.
You will be responsible for any Copay, Coinsurance or Deductible payments as part of the
COB payment. The maximum combined payment you may receive from all plans cannot
exceed 100% of the total allowable expense. See the textbox below for the definition of
allowable expense.
Determining the Allowable Expense If This Plan is Secondary
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 the provider is a Network provider for both the primary plan and this Plan, the
allowable expense is the primary plan's network rate. When the provider is a network
provider for the primary plan and a non-Network provider for this Plan, the allowable
expense is the primary plan's network rate. When the provider is a non-Network provider
for the primary plan and a Network provider for this Plan, the allowable expense is the
reasonable and customary charges allowed by the primary plan. When the provider is a non-
Network provider for both the primary plan and this Plan, the allowable expense is the
greater of the two Plans' reasonable and customary charges. If this plan is secondary to
Medicare, please also refer to the discussion in the section below, titled Determining the
Allowable Expense When This Plan is Secondary to Medicare.
When a Covered Person Qualifies for Medicare
Determining Which Plan is Primary
As permitted by law, this Plan 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 Plan 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 (however, domestic partners are excluded as provided by Medicare).
■ Individuals with end-stage renal disease, for a limited period of time.
CITY OF DENTON GOLD MEDICAL PLAN
90 SECTION 10 - COORDINATION OF BENEFITS (COB)
■ Disabled individuals under age 65 with current employment status and their Dependents
under age 65.
Determining the Allowable Expense When This Plan is Secondary to Medicare
If this Plan is secondary to Medicare, the Medicare approved amount is the allowable
expense, as long as the provider accepts reimbursement directly from Medicare. If the
provider accepts reimbursement directly from Medicare, the Medicare approved amount is
the charge that Medicare has determined that it will recognize and which it reports on an
"explanation of Medicare benefits" issued by Medicare (the "EOMB") for a given service.
Medicare typically reimburses such providers a percentage of its approved charge – often
80%.
If the provider does not accept assignment of your Medicare benefits, the Medicare limiting
charge (the most a provider can charge you if they don't accept Medicare – typically 115% of
the Medicare approved amount) will be the allowable expense. Medicare payments,
combined with Plan Benefits, will not exceed 100% of the allowable expense.
If you are eligible for, but not enrolled in, Medicare, and this Plan is secondary to Medicare,
or if you have enrolled in Medicare but choose to obtain services from a provider that does
not participate in the Medicare program (as opposed to a provider who does not accept
assignment of Medicare benefits), Benefits will be paid on a secondary basis under this Plan
and will be determined as if you timely enrolled in Medicare and obtained services from a
Medicare participating provider.
When calculating the Plan's Benefits in these situations, for administrative convenience
UnitedHealthcare will treat the provider's billed charges for covered services as the allowable
expense for both the Plan and Medicare, rather than the Medicare approved amount or
Medicare limiting charge.
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.
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 cross-over process does not apply to expenses that Medicare does not cover. You must
go on to file claims for these expenses.
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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 this Plan and other plans. UnitedHealthcare 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.
UnitedHealthcare does not need to tell, or get the consent of, any person to do this. Each
person claiming benefits under this Plan 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 the Plan should have paid. If this occurs, the Plan may pay the
other plan the amount owed.
If the Plan 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 this Plan.
The Company also reserves the right to recover any overpayment by legal action or offset
payments on future Eligible Expenses.
If the Plan overpays a health care provider, UnitedHealthcare reserves the right to recover
the excess amount from the provider pursuant to Refund of Overpayments, below.
Refund of Overpayments
If the Plan 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:
■ The Plan's obligation to pay Benefits was contingent on the expenses incurred being
legally owed and paid by the Covered Person, but 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 Plan.
■ All or some of the payment was made in error.
The amount that must be refunded equals the amount the Plan paid in excess of the amount
that should have been paid under the Plan. If the refund is due from another person or
organization, the Covered Person agrees to help the Plan get the refund when requested.
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If the refund is due from the Covered Person and the Covered Person does not promptly
refund the full amount owed, the Plan may recover the overpayment by reallocating the
overpaid amount to pay, in whole or in part, future Benefits for the Covered Person that are
payable under the Plan. If the refund is due from a person or organization other than the
Covered Person, the Plan may recover the overpayment by reallocating the overpaid amount
to pay, in whole or in part, (i) future Benefits that are payable in connection with services
provided to other Covered Persons under the Plan; or (ii) future benefits that are payable in
connection with services provided to persons under other plans for which UnitedHealthcare
makes payments, pursuant to a transaction in which the Plan’s overpayment recovery rights
are assigned to such other plans in exchange for such plans’ remittance of the amount of the
reallocated payment. The reallocated payment amount will equal the amount of the required
refund or, if less than the full amount of the required refund, will be deducted from the
amount of refund owed to the Plan. The Plan may have other rights in addition to the right
to reallocate overpaid amounts and other enumerated rights, including the right to
commence a legal action.
CITY OF DENTON GOLD MEDICAL PLAN
93 SECTION 11 - SUBROGATION AND REIMBURSEMENT
SECTION 11 - SUBROGATION AND REIMBURSEMENT
The Plan has a right to subrogation and reimbursement.
Subrogation applies when the plan has paid Benefits on your behalf for a Sickness or Injury
for which a third party is alleged to be responsible. The right to subrogation means that the
Plan is substituted to and shall succeed to any and all legal claims that you may be entitled to
pursue against any third party for the Benefits that the Plan has paid that are related to the
Sickness or Injury for which a third party is alleged to be responsible.
Subrogation - Example
Suppose you are injured in a car accident that is not your fault, and you receive Benefits
under the Plan to treat your injuries. Under subrogation, the Plan has the right to take
legal action in your name against the driver who caused the accident and that driver's
insurance carrier to recover the cost of those Benefits.
The right to reimbursement means that if a third party causes or is alleged to have caused a
Sickness or Injury for which you receive a settlement, judgment, or other recovery from any
third party, you must use those proceeds to fully return to the Plan 100% of any Benefits
you received for that Sickness or Injury.
Reimbursement - Example
Suppose you are injured in a boating accident that is not your fault, and you receive
Benefits under the Plan as a result of your injuries. In addition, you receive a settlement in
a court proceeding from the individual who caused the accident. You must use the
settlement funds to return to the plan 100% of any Benefits you received to treat your
injuries.
The following persons and entities are considered third parties:
■ A person or entity alleged to have caused you to suffer a Sickness, Injury or damages, or
who is legally responsible for the Sickness, Injury or damages.
■ Any insurer or other indemnifier of any person or entity alleged to have caused or who
caused the Sickness, Injury or damages.
■ The Plan Sponsor (for example workers' compensation cases).
■ Any person or entity who is or may be obligated to provide benefits or payments to you,
including benefits or payments for underinsured or uninsured motorist protection, no-
fault or traditional auto insurance, medical payment coverage (auto, homeowners or
otherwise), workers' compensation coverage, other insurance carriers or third party
administrators.
■ Any person or entity that is liable for payment to you on any equitable or legal liability
theory.
CITY OF DENTON GOLD MEDICAL PLAN
94 SECTION 11 - SUBROGATION AND REIMBURSEMENT
You agree as follows:
■ You will cooperate with the Plan in protecting its legal and equitable rights to
subrogation and reimbursement in a timely manner, including, but not limited to:
- Notifying the Plan, in writing, of any potential legal claim(s) you may have against
any third party for acts which caused Benefits to be paid or become payable.
- Providing any relevant information requested by the Plan.
- Signing and/or delivering such documents as the Plan or its agents reasonably
request to secure the subrogation and reimbursement claim.
- Responding to requests for information about any accident or injuries.
- Making court appearances.
- Obtaining the Plan's consent or its agents' consent before releasing any party from
liability or payment of medical expenses.
- Complying with the terms of this section.
Your failure to cooperate with the Plan is considered a breach of contract. As such, the
Plan has the right to terminate your Benefits, deny future Benefits, take legal action
against you, and/or set off from any future Benefits the value of Benefits the Plan has
paid relating to any Sickness or Injury alleged to have been caused or caused by any third
party to the extent not recovered by the Plan due to you or your representative not
cooperating with the Plan. If the Plan incurs attorneys' fees and costs in order to collect
third party settlement funds held by you or your representative, the Plan has the right to
recover those fees and costs from you. You will also be required to pay interest on any
amounts you hold which should have been returned to the Plan.
■ The Plan has a first priority right to receive payment on any claim against a third party
before you receive payment from that third party. Further, the Plan's first priority right
to payment is superior to any and all claims, debts or liens asserted by any medical
providers, including but not limited to Hospitals or emergency treatment facilities, that
assert a right to payment from funds payable from or recovered from an allegedly
responsible third party and/or insurance carrier.
■ The Plan's subrogation and reimbursement rights apply to full and partial settlements,
judgments, or other recoveries paid or payable to you or your representative, no matter
how those proceeds are captioned or characterized. Payments include, but are not
limited to, economic, non-economic, and punitive damages. The Plan is not required to
help you to pursue your claim for damages or personal injuries and no amount of
associated costs, including attorneys' fees, shall be deducted from the Plan's recovery
without the Plan's express written consent. No so-called "Fund Doctrine" or "Common
Fund Doctrine" or "Attorney's Fund Doctrine" shall defeat this right.
■ Regardless of whether you have been fully compensated or made whole, the Plan may
collect from you the proceeds of any full or partial recovery that you or your legal
representative obtain, whether in the form of a settlement (either before or after any
determination of liability) or judgment, no matter how those proceeds are captioned or
characterized. Proceeds from which the Plan may collect include, but are not limited to,
economic, non-economic, and punitive damages. No "collateral source" rule, any "Made-
Whole Doctrine" or "Make-Whole Doctrine," claim of unjust enrichment, nor any other
equitable limitation shall limit the Plan's subrogation and reimbursement rights.
CITY OF DENTON GOLD MEDICAL PLAN
95 SECTION 11 - SUBROGATION AND REIMBURSEMENT
■ Benefits paid by the Plan may also be considered to be Benefits advanced.
■ If you receive any payment from any party as a result of Sickness or Injury, and the Plan
alleges some or all of those funds are due and owed to the Plan, you shall hold those
funds in trust, either in a separate bank account in your name or in your attorney's trust
account. You agree that you will serve as a trustee over those funds to the extent of the
Benefits the Plan has paid.
■ The Plan's rights to recovery will not be reduced due to your own negligence.
■ Upon the Plan's request, you will assign to the Plan all rights of recovery against third
parties, to the extent of the Benefits the Plan has paid for the Sickness or Injury.
■ The Plan may, at its option, take necessary and appropriate action to preserve its rights
under these subrogation provisions, including but not limited to, providing or
exchanging medical payment information with an insurer, the insurer's legal
representative or other third party and filing suit in your name, which does not obligate
the Plan in any way to pay you part of any recovery the Plan might obtain.
■ You may not accept any settlement that does not fully reimburse the Plan, without its
written approval.
■ The Plan has the authority and discretion to resolve all disputes regarding the
interpretation of the language stated herein.
■ In the case of your wrongful death or survival claim, the provisions of this section apply
to your estate, the personal representative of your estate, and your heirs or beneficiaries.
■ No allocation of damages, settlement funds or any other recovery, by you, your estate,
the personal representative of your estate, your heirs, your beneficiaries or any other
person or party, shall be valid if it does not reimburse the Plan for 100% of its interest
unless the Plan provides written consent to the allocation.
■ The provisions of this section apply to the parents, guardian, or other representative of a
Dependent child who incurs a Sickness or Injury caused by a third party. If a parent or
guardian may bring a claim for damages arising out of a minor's Sickness or Injury, the
terms of this subrogation and reimbursement clause shall apply to that claim.
■ If a third party causes or is alleged to have caused you to suffer a Sickness or Injury while
you are covered under this Plan, the provisions of this section continue to apply, even
after you are no longer covered.
■ The Plan and all Administrators administering the terms and conditions of the Plan's
subrogation and reimbursement rights have such powers and duties as are necessary to
discharge its duties and functions, including the exercise of its discretionary authority to
(1) construe and enforce the terms of the Plan's subrogation and reimbursement rights
and (2) make determinations with respect to the subrogation amounts and
reimbursements owed to the Plan.
CITY OF DENTON GOLD MEDICAL PLAN
96 SECTION 11 - SUBROGATION AND REIMBURSEMENT
Right of Recovery
The Plan also has the right to recover benefits it has paid on you or your Dependent's behalf
that were:
■ Made in error.
■ Due to a mistake in fact.
■ Advanced during the time period of meeting the calendar year Deductible.
■ Advanced during the time period of meeting the Out-of-Pocket Maximum for the
calendar year.
Benefits paid because you or your Dependent misrepresented facts are also subject to
recovery.
If the Plan provides a Benefit for you or your Dependent that exceeds the amount that
should have been paid, the Plan will:
■ Require that the overpayment be returned when requested.
■ Reduce a future benefit payment for you or your Dependent by the amount of the
overpayment.
If the Plan provides an advancement of benefits to you or your Dependent during the time
period of meeting the Deductible and/or meeting the Out-of-Pocket Maximum for the
calendar year, the Plan will send you or your Dependent a monthly statement identifying the
amount you owe with payment instructions. The Plan has the right to recover Benefits it has
advanced by:
■ Submitting a reminder letter to you or a covered Dependent that details any outstanding
balance owed to the Plan.
■ Conducting courtesy calls to you or a covered Dependent to discuss any outstanding
balance owed to the Plan.
CITY OF DENTON GOLD MEDICAL PLAN
97 SECTION 12 - WHEN COVERAGE ENDS
SECTION 12 - WHEN COVERAGE ENDS
What this section includes:
■ Circumstances that cause coverage to end.
■ Extended coverage.
■ How 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. Please note that
this does not affect coverage that is extended under Extended Coverage for Total Disability
below.
When your coverage ends, City of Denton 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. Please note that this
does not affect coverage that is extended under Extended Coverage for Total Disability below.
Your coverage under the Plan will end on the earliest of:
■ The last day of the month your employment with the Company ends.
■ The date the Plan ends.
■ The last day of the month you stop making the required contributions.
■ The last day of the month you are no longer eligible.
■ The last day of the month UnitedHealthcare receives written notice from City of Denton
to end your coverage, or the date requested in the notice, if later.
■ The last day of the month you retire or are pensioned under the Plan, unless specific
coverage is available for retired or pensioned persons and you are eligible for that
coverage.
Coverage for your eligible Dependents will end on the earliest of:
■ The date your coverage ends.
■ The last day of the month you stop making the required contributions.
■ The last day of the month UnitedHealthcare receives written notice from City of Denton
to end your coverage, or the date requested in the notice, if later.
■ The last day of the month your Dependents no longer qualify as Dependents under this
Plan.
Other Events Ending Your Coverage
The Plan will provide at least thirty days' prior written notice to you that your coverage will
end on the date identified in the notice if you commit an act, practice, or omission that
CITY OF DENTON GOLD MEDICAL PLAN
98 SECTION 12 - WHEN COVERAGE ENDS
constituted fraud, or an intentional misrepresentation of a material fact including, but not
limited to, knowingly providing incorrect information relating to another person's eligibility
or status as a Dependent. You may appeal this decision during the 30-day notice period. The
notice will contain information on how to pursue your appeal.
Note: If UnitedHealthcare and City of Denton find that you have performed an act,
practice, or omission that constitutes fraud, or have made an intentional misrepresentation
of material fact City of Denton has the right to demand that you pay back all Benefits City of
Denton paid to you, or paid in your name, during the time you were incorrectly covered
under the Plan.
Coverage for a Disabled Child
If an unmarried enrolled Dependent child with a mental or physical disability reaches an age
when coverage would otherwise end, the Plan will continue to cover the child, as long as:
■ The child is unable to be self-supporting due to a mental or physical handicap or
disability.
■ The child depends mainly on you for support.
■ You provide to City of Denton proof of the child's incapacity and dependency within 31
days of the date coverage would have otherwise ended because the child reached a
certain age.
■ You provide proof, upon City of Denton's request, that the child continues to meet
these conditions.
The proof might include medical examinations at City of Denton's expense. However, you
will not be asked for this information more than once a year. If you do not supply such
proof within 31 days, the Plan will no longer pay Benefits for that child.
Coverage will continue, as long as the enrolled Dependent is incapacitated and dependent
upon you, unless coverage is otherwise terminated in accordance with the terms of the Plan.
Extended Coverage for Total Disability
If a Covered Person has a Total Disability on the date their coverage under the Plan ends,
their Benefits will not end automatically. The Plan will temporarily extend coverage, only for
treatment of the condition causing the Total Disability. Benefits will be paid until the earlier
of:
■ The Total Disability ends.
■ three months from the date coverage would have ended.
Continuing Coverage Through 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 14, Glossary.
CITY OF DENTON GOLD MEDICAL PLAN
99 SECTION 12 - WHEN COVERAGE ENDS
Continuation coverage under COBRA is available only to Plans that are subject to the terms
of COBRA. You can contact your Plan Administrator to determine if City of Denton is
subject to the provisions of COBRA.
Continuation Coverage under Federal Law (COBRA)
Much of the language in this section comes from the federal law that governs continuation
coverage. You should call your Plan Administrator if you have questions about your right to
continue coverage.
In order to be eligible for continuation coverage under federal law, you must meet the
definition of a "Qualified Beneficiary". A Qualified Beneficiary is any of the following
persons who were covered under the Plan on the day before a qualifying event:
■ A Participant.
■ A Participant's enrolled Dependent, including with respect to the Participant's children, a
child born to or placed for adoption with the Participant during a period of continuation
coverage under federal law.
■ A Participant's former Spouse.
Qualifying Events for Continuation Coverage under COBRA
The following table outlines situations in which you may elect to continue coverage under
COBRA for yourself and your Dependents, and the maximum length of time you can
receive continued coverage. These situations are considered qualifying events.
If Coverage Ends Because of
the Following Qualifying
Events:
You May Elect COBRA:
For Yourself For Your Spouse For Your
Child(ren)
Your work hours are reduced 18 months 18 months 18 months
Your employment terminates for
any reason (other than gross
misconduct)
18 months 18 months 18 months
You or your family member
become eligible for Social Security
disability benefits at any time
within the first 60 days of losing
coverage1
29 months 29 months 29 months
You die N/A 36 months 36 months
You divorce (or legally separate) N/A 36 months 36 months
Your child is no longer an eligible
family member (e.g., reaches the
maximum age limit)
N/A N/A 36 months
CITY OF DENTON GOLD MEDICAL PLAN
100 SECTION 12 - WHEN COVERAGE ENDS
If Coverage Ends Because of
the Following Qualifying
Events:
You May Elect COBRA:
For Yourself For Your Spouse For Your
Child(ren)
You become entitled to Medicare N/A See table below See table
below
City of Denton files for
bankruptcy under Title 11, United
States Code.2
36 months 36 months3 36 months3
1Subject to the following conditions: (i) notice of the disability must be provided within the latest of
60 days after a). the determination of the disability, b). the date of the qualifying event, c). the date
the Qualified Beneficiary would lose coverage under the Plan, and in no event later than the end of
the first 18 months; (ii) the Qualified Beneficiary must agree to pay any increase in the required
premium for the additional 11 months over the original 18 months; and (iii) if the Qualified
Beneficiary entitled to the 11 months of coverage has non-disabled family members who are also
Qualified Beneficiaries, then those non-disabled Qualified Beneficiaries are also entitled to the
additional 11 months of continuation coverage. Notice of any final determination that the Qualified
Beneficiary is no longer disabled must be provided within 30 days of such determination. Thereafter,
continuation coverage may be terminated on the first day of the month that begins more than 30
days after the date of that determination.
2This is a qualifying event for any retired Participant and his or her enrolled Dependents if there is a
substantial elimination of coverage within one year before or after the date the bankruptcy was filed.
3From the date of the Participant's death if the Participant dies during the continuation coverage.
How Your Medicare Eligibility Affects Dependent COBRA Coverage
The table below outlines how your Dependents' COBRA coverage is impacted if you
become entitled to Medicare.
If Dependent Coverage Ends When:
You May Elect
COBRA Dependent
Coverage For Up To:
You become entitled to Medicare and don't experience any
additional qualifying events 18 months
You become entitled to Medicare, after which you experience
a second qualifying event* before the initial 18-month period
expires
36 months
You experience a qualifying event*, after which you become
entitled to Medicare before the initial 18-month period
expires; and, if absent this initial qualifying event, your
Medicare entitlement would have resulted in loss of
Dependent coverage under the Plan
36 months
CITY OF DENTON GOLD MEDICAL PLAN
101 SECTION 12 - WHEN COVERAGE ENDS
* Your work hours are reduced or your employment is terminated for reasons other than gross
misconduct.
Getting Started
You will be notified by mail if you become eligible for COBRA coverage as a result of a
reduction in work hours or termination of employment. The notification will give you
instructions for electing COBRA coverage, and advise you of the monthly cost. Your
monthly cost is the full cost, including both Participant and Employer costs, plus a 2%
administrative fee or other cost as permitted by law.
You will have up to 60 days from the date you receive notification or 60 days from the date
your coverage ends to elect COBRA coverage, whichever is later. You will then have an
additional 45 days to pay the cost of your COBRA coverage, retroactive to the date your
Plan coverage ended.
During the 60-day election period, the Plan will, only in response to a request from a
provider, inform that provider of your right to elect COBRA coverage, retroactive to the
date your COBRA eligibility began.
While you are a participant in the medical Plan under COBRA, you have the right to change
your coverage election:
■ During Open Enrollment.
■ Following a change in family status, as described under Changing Your Coverage in Section
2, Introduction.
Notification Requirements
If your covered Dependents lose coverage due to divorce, legal separation, or loss of
Dependent status, you or your Dependents must notify the Plan Administrator within 60
days of the latest of:
■ The date of the divorce, legal separation or an enrolled Dependent's loss of eligibility as
an enrolled Dependent.
■ The date your enrolled Dependent would lose coverage under the Plan.
■ The date on which you or your enrolled Dependent are informed of your obligation to
provide notice and the procedures for providing such notice.
You or your Dependents must also notify the Plan Administrator when a qualifying event
occurs that will extend continuation coverage.
If you or your Dependents fail to notify the Plan Administrator of these events within the 60
day period, the Plan Administrator is not obligated to provide continued coverage to the
affected Qualified Beneficiary. If you are continuing coverage under federal law, you must
notify the Plan Administrator within 60 days of the birth or adoption of a child.
CITY OF DENTON GOLD MEDICAL PLAN
102 SECTION 12 - WHEN COVERAGE ENDS
Once you have notified the Plan Administrator, you will then be notified by mail of your
election rights under COBRA.
Notification Requirements for Disability Determination
If you extend your COBRA coverage beyond 18 months because you are eligible for
disability benefits from Social Security, you must provide Human Resources with notice of
the Social Security Administration's determination within 60 days after you receive that
determination, and before the end of your initial 18-month continuation period.
The notice requirements will be satisfied by providing written notice to the Plan
Administrator. The contents of the notice must be such that the Plan Administrator is able
to determine the covered Employee and qualified beneficiary(ies), the qualifying event or
disability, and the date on which the qualifying event occurred.
Trade Act of 2002
The Trade Act of 2002 amended COBRA to provide for a special second 60-day COBRA
election period for certain Participants who have experienced a termination or reduction of
hours and who lose group health plan coverage as a result. The special second COBRA
election period is available only to a very limited group of individuals: generally, those who
are receiving trade adjustment assistance (TAA) or 'alternative trade adjustment assistance'
under a federal law called the Trade Act of 1974. These Participants are entitled to a second
opportunity to elect COBRA coverage for themselves and certain family members (if they
did not already elect COBRA coverage), but only within a limited period of 60 days from the
first day of the month when an individual begins receiving TAA (or would be eligible to
receive TAA but for the requirement that unemployment benefits be exhausted) and only
during the six months immediately after their group health plan coverage ended.
If a Participant qualifies or may qualify for assistance under the Trade Act of 1974, he or she
should contact the Plan Administrator for additional information. The Participant must
contact the Plan Administrator promptly after qualifying for assistance under the Trade Act
of 1974 or the Participant will lose his or her special COBRA rights. COBRA coverage
elected during the special second election period is not retroactive to the date that Plan
coverage was lost, but begins on the first day of the special second election period.
When COBRA Ends
COBRA coverage will end before the maximum continuation period, on the earliest of the
following dates:
■ The date, after electing continuation coverage, that coverage is first obtained under any
other group health plan.
■ The date, after electing continuation coverage, that you or your covered Dependent first
becomes entitled to Medicare.
■ The date coverage ends for failure to make the first required premium payment
(premium is not paid within 45 days).
■ The date coverage ends for failure to make any other monthly premium payment
(premium is not paid within 30 days of its due date).
CITY OF DENTON GOLD MEDICAL PLAN
103 SECTION 12 - WHEN COVERAGE ENDS
■ The date the entire Plan ends.
■ The date coverage would otherwise terminate under the Plan as described in the
beginning of this section.
Note: If you selected continuation coverage under a prior plan which was then replaced by
coverage under this Plan, continuation coverage will end as scheduled under the prior plan
or in accordance with the terminating events listed in this section, whichever is earlier.
Uniformed Services Employment and Reemployment Rights Act
A Participant who is absent from employment for more than 30 days by reason of service in
the Uniformed Services may elect to continue Plan coverage for the Participant and the
Participant's Dependents in accordance with the Uniformed Services Employment and
Reemployment Rights Act of 1994, as amended (USERRA).
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.
If qualified to continue coverage pursuant to the USERRA, Participants may elect to
continue coverage under the Plan by notifying the Plan Administrator in advance, and
providing payment of any required contribution for the health coverage. This may include
the amount the Plan Administrator normally pays on a Participant's behalf. If a Participant's
Military Service is for a period of time less than 31 days, the Participant may not be required
to pay more than the regular contribution amount, if any, for continuation of health
coverage.
A Participant may continue Plan coverage under USERRA for up to the lesser of:
■ The 24 month period beginning on the date of the Participant's absence from work.
■ The day after the date on which the Participant fails to apply for, or return to, a position
of employment.
Regardless of whether a Participant continues health coverage, if the Participant returns to a
position of employment, the Participant's health coverage and that of the Participant's
eligible Dependents will be reinstated under the Plan. No exclusions or waiting period may
be imposed on a Participant or the Participant's 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.
You should call the Plan Administrator if you have questions about your rights to continue
health coverage under USERRA.
CITY OF DENTON GOLD MEDICAL PLAN
104 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 City of Denton.
■ Relationships with providers.
■ Interpretation of Benefits.
■ Information and records.
■ Incentives to providers and you.
■ The future of the Plan.
■ How to access the official Plan documents.
Qualified Medical Child Support Orders (QMCSOs)
A qualified medical child support order (QMCSO) is a judgment, decree or order issued by a
court or appropriate state agency that requires a child to be covered for medical benefits.
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.
You may obtain, without charge, a copy of the procedures governing QMCSOs from the
Plan Administrator.
Note: A National Medical Support Notice will be recognized as a QMCSO if it meets the
requirements of a QMCSO.
Your Relationship with UnitedHealthcare and City of Denton
In order to make choices about your health care coverage and treatment, City of Denton
believes that it is important for you to understand how UnitedHealthcare interacts with the
Plan Sponsor's benefit Plan and how it may affect you. UnitedHealthcare helps administer
the Plan Sponsor's benefit plan in which you are enrolled. UnitedHealthcare does not
provide medical services or make treatment decisions. This means:
■ 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.
■ 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.
CITY OF DENTON GOLD MEDICAL PLAN
105 SECTION 13 - OTHER IMPORTANT INFORMATION
City of Denton 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. City of Denton and UnitedHealthcare will use individually identifiable information
about you as permitted or required by law, including in operations and in research. City of
Denton and UnitedHealthcare will use de-identified data for commercial purposes including
research.
Relationship with Providers
The relationships between City of Denton, UnitedHealthcare and Network providers are
solely contractual relationships between independent contractors. Network providers are not
City of Denton's agents or employees, nor are they agents or employees of
UnitedHealthcare. City of Denton and any of its employees are not agents or employees of
Network providers, nor are UnitedHealthcare and any of its employees agents or employees
of Network providers.
City of Denton and UnitedHealthcare do not provide health care services or supplies, nor do
they practice medicine. Instead, City of Denton and UnitedHealthcare arrange 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
credentialing process confirms public information about the providers' licenses and other
credentials, but does not assure the quality of the services provided. They are not City of
Denton's employees nor are they employees of UnitedHealthcare. City of Denton and
UnitedHealthcare do not have any other relationship with Network providers such as
principal-agent or joint venture. City of Denton and UnitedHealthcare are not liable for any
act or omission of any provider.
UnitedHealthcare is not considered to be an employer of the Plan Administrator for any
purpose with respect to the administration or provision of benefits under this Plan.
City of Denton 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 the service fee to UnitedHealthcare.
■ The funding of Benefits on a timely basis.
■ 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. You:
■ Are responsible for choosing your own provider.
■ Are responsible for paying, directly to your provider, any amount identified as a member
responsibility, including Copayments, Coinsurance, any deductible and any amount that
exceeds Eligible Expenses.
CITY OF DENTON GOLD MEDICAL PLAN
106 SECTION 13 - OTHER IMPORTANT INFORMATION
■ 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).
■ Must decide with your provider what care you should receive.
Your provider is solely responsible for the quality of the services provided to you.
The relationship between you and City of Denton is that of employer and employee,
Dependent or other classification as defined in this SPD.
Interpretation of Benefits
City of Denton 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 Summary of Material Modifications and/or Amendments.
■ Make factual determinations related to the Plan and its Benefits.
City of Denton 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, City of Denton
may, in its discretion, offer Benefits for services that would otherwise not be Covered Health
Services. The fact that City of Denton does so in any particular case shall not in any way be
deemed to require City of Denton to do so in other similar cases.
Information and Records
City of Denton and UnitedHealthcare may use your individually identifiable health
information to administer the Plan and pay claims, to identify procedures, products, or
services that you may find valuable, and as otherwise permitted or required by law. City of
Denton and UnitedHealthcare may request additional information from you to decide your
claim for Benefits. City of Denton and UnitedHealthcare will keep this information
confidential. City of Denton and UnitedHealthcare may also use your de-identified data for
commercial purposes, including research, as permitted by law.
By accepting Benefits under the Plan, you authorize and direct any person or institution that
has provided services to you to furnish City of Denton and UnitedHealthcare with all
information or copies of records relating to the services provided to you. City of Denton
and UnitedHealthcare have the right to request this information at any reasonable time. This
applies to all Covered Persons, including enrolled Dependents whether or not they have
signed the Participant's enrollment form. City of Denton and UnitedHealthcare agree that
such information and records will be considered confidential.
CITY OF DENTON GOLD MEDICAL PLAN
107 SECTION 13 - OTHER IMPORTANT INFORMATION
City of Denton and UnitedHealthcare have the right to release any and all records
concerning health care services which are necessary to implement and administer the terms
of the Plan, for appropriate medical review or quality assessment, or as City of Denton is
required to do by law or regulation. During and after the term of the Plan, City of Denton
and UnitedHealthcare and its related entities may use and transfer the information gathered
under the Plan in a de-identified format for commercial purposes, including research and
analytic purposes.
For complete listings of your medical records or billing statements City of Denton
recommends that you contact your health care provider. Providers may charge you
reasonable fees to cover their costs for providing records or completing requested forms.
If you request medical forms or records from UnitedHealthcare, they also may charge you
reasonable fees to cover costs for completing the forms or providing the records.
In some cases, City of Denton and UnitedHealthcare will designate other persons or entities
to request records or information from or related to you, and to release those records as
necessary. UnitedHealthcare's designees have the same rights to this information as does the
Plan Administrator.
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.
■ 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.
Incentives to You
Sometimes you may be offered coupons or other incentives to encourage you to participate
in various wellness programs or certain disease management programs. The decision about
whether or not to participate is yours alone but City of Denton recommends that you
discuss participating in such programs with your Physician. These incentives are not Benefits
CITY OF DENTON GOLD MEDICAL PLAN
108 SECTION 13 - OTHER IMPORTANT INFORMATION
and do not alter or affect your Benefits. You may call the number on the back of your ID
card if you have any questions.
Rebates and Other Payments
City of Denton and UnitedHealthcare may receive rebates for certain drugs that are
administered to you in a Physician's office, or at a Hospital or Alternate Facility. This
includes rebates for those drugs that are administered to you before you meet your Annual
Deductible. City of Denton and UnitedHealthcare do not pass these rebates on to you, nor
are they applied to your Annual Deductible or taken into account in determining your
Copays or Coinsurance.
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.
Future of the Plan
Although the Company expects to continue the Plan indefinitely, it reserves the right to
discontinue, alter or modify the Plan in whole or in part, at any time and for any reason, at
its sole determination.
The Company's decision to terminate or amend a Plan may be due to changes in federal or
state laws governing employee benefits, the requirements of the Internal Revenue Code or
any other reason. A plan change may transfer plan assets and debts to another plan or split a
plan into two or more parts. If the Company does change or terminate a plan, it may decide
to set up a different plan providing similar or different benefits.
If this Plan is terminated, Covered Persons will not have the right to any other Benefits from
the Plan, other than for those claims incurred prior to the date of termination, or as
otherwise provided under the Plan. In addition, if the Plan is amended, Covered Persons
may be subject to altered coverage and Benefits.
The amount and form of any final benefit you receive will depend on any Plan document or
contract provisions affecting the Plan and Company decisions. After all Benefits have been
paid and other requirements of the law have been met, certain remaining Plan assets will be
turned over to the Company and others as may be required by any applicable law.
Plan Document
This Summary Plan Description (SPD) represents an overview of your Benefits. In the event
there is a discrepancy between the SPD and the official plan document, the plan document
will govern. A copy of the plan document is available for your inspection during regular
business hours in the office of the Plan Administrator. You (or your personal representative)
may obtain a copy of this document by written request to the Plan Administrator, for a
nominal charge.
CITY OF DENTON GOLD MEDICAL PLAN
109 SECTION 14 - GLOSSARY
SECTION 14 - 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.
Addendum - any attached written description of additional or revised provisions to the
Plan. The benefits and exclusions of this SPD and any amendments thereto shall apply to
the Addendum except that in the case of any conflict between the Addendum and SPD
and/or Amendments to the SPD, the Addendum shall be controlling.
Alternate Facility - a health care facility that is not a Hospital and that provides one or
more of the following services on an outpatient basis, as permitted by law:
■ Surgical services.
■ Emergency Health Services.
■ Rehabilitative, laboratory, diagnostic or therapeutic services.
An Alternate Facility may also provide Mental Health Services or Substance-Related and
Addictive Disorders 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 effective only when distributed by the Plan Sponsor or the Plan
Administrator. Amendments are subject to all conditions, limitations and exclusions of the
Plan, except for those that the amendment is specifically changing.
Annual Deductible (or Deductible) - the amount of Eligible Expenses you must pay for
Covered Health Services in a calendar year before you are eligible to begin receiving Benefits
in that calendar year. The Deductible is shown in the first table in Section 5, Plan Highlights.
Autism Spectrum Disorder - 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 City of Denton. The BRS program provides:
■ Specialized clinical consulting services to Participants and enrolled Dependents to
educate on obesity treatment options.
■ Access to specialized Network facilities and Physicians for obesity surgery services.
CITY OF DENTON GOLD MEDICAL PLAN
110 SECTION 14 - GLOSSARY
Benefits - Plan payments for Covered Health Services, subject to the terms and conditions
of the Plan and any Addendums and/or Amendments.
BMI - see Body Mass Index (BMI).
Body Mass Index (BMI) - a calculation used in obesity risk assessment which uses a
person's weight and height to approximate body fat.
Cancer Resource Services (CRS) - a program administered by UnitedHealthcare or its
affiliates made available to you by City of Denton. The CRS program provides:
■ Specialized consulting services, on a limited basis, to Participants and enrolled
Dependents with cancer.
■ Access to cancer centers with expertise in treating the most rare or complex cancers.
■ Education to help patients understand their cancer and make informed decisions about
their care and course of treatment.
Care CoordinationSM - programs provided by UnitedHealthcare 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.
CHD - see Congenital Heart Disease (CHD).
Claims Administrator - UnitedHealthcare (also known as United Healthcare 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 charge, stated as a percentage of Eligible Expenses, that you are required
to pay for certain Covered Health Services as described in Section 3, How the Plan Works and
Section 15, Outpatient Prescription Drugs.
Company - City of Denton.
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.
CITY OF DENTON GOLD MEDICAL PLAN
111 SECTION 14 - GLOSSARY
■ Have no known cause.
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) - a federal law
that requires employers to offer continued health insurance coverage to certain employees
and their dependents whose group health insurance has been terminated.
Copayment (or Copay) - the charge, stated as a set dollar amount, that you are required to
pay for certain Covered Health Services as described in Section 3, How the Plan Works and
Section 15, Outpatient Prescription Drugs.
Please note that for Covered Health Services, you are responsible for paying the lesser of the
following:
■ The applicable Copayment.
■ The Eligible Expense.
Cosmetic Procedures - procedures or services that change or improve appearance without
significantly improving physiological function, as determined by the Claims Administrator.
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 the Claims Administrator determines to be:
■ Medically Necessary.
■ Described as a Covered Health Service in this SPD under Section 5, Plan Highlights and 6,
Additional Coverage Details and Section 15, Outpatient Prescription Drugs.
■ Provided to a Covered Person who meets the Plan's eligibility requirements, as described
under Eligibility in Section 2, Introduction.
■ Not otherwise excluded in this SPD under Section 8, Exclusions and Limitations or Section
15, Outpatient Prescription Drugs.
Covered Person - either the Participant or an enrolled Dependent, but this term applies only
while the person is enrolled and eligible for Benefits under the Plan. References to "you" and
"your" throughout this SPD are references to a Covered Person.
Covered Person - either the Participant or an enrolled Dependent, but this term applies
only while the person is 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 are any of the following:
■ Non-health-related services, such as assistance in activities of daily living (examples
include feeding, dressing, bathing, transferring and ambulating).
CITY OF DENTON GOLD MEDICAL PLAN
112 SECTION 14 - GLOSSARY
■ Health-related services that are provided for the primary purpose of meeting the
personal needs of the patient or maintaining a level of function (even if the specific
services are considered to be skilled services), as opposed to improving that function to
an extent that might allow for a more independent existence.
■ Services that do not require continued administration by trained medical personnel in
order to be delivered safely and effectively.
Deductible - see Annual Deductible.
Dependent - an individual who meets the eligibility requirements specified in the Plan, as
described under Eligibility in Section 2, Introduction. A Dependent does not include anyone
who is also enrolled as a Participant. No one can be a Dependent of more than one
Participant.
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 render Covered
Health Services for the treatment of specified diseases or conditions. A Designated Facility
may or may not be located within your geographic area. The fact that a Hospital is a
Network Hospital does not mean that it is a Designated Facility.
Designated Network Benefits - for Benefit plans that have a Designated Network Benefit
level, this is the description of how Benefits are paid for the Covered Health Services
provided by a Physician or other provider that the Claims Administrator has identified as
Designated Network providers. Refer to Section 5, Plan Highlights, to determine whether or
not your Benefit plan offers Designated Network Benefits and for details about how
Designated Network Benefits apply.
Designated Physician - a Physician that the Claims Administrator identified through its
designation programs as a Designated provider. A Designated Physician may or may not be
located within your geographic area. The fact that a Physician is a Network Physician does
not mean that he or she is a Designated Physician.
Designated Virtual Network Provider - a provider or facility that has entered into an
agreement with UnitedHealthcare, or with an organization contracting on
UnitedHealthcare'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:
■ Is used to serve a medical purpose with respect to treatment of a Sickness, Injury or their
symptoms.
■ Is not disposable.
CITY OF DENTON GOLD MEDICAL PLAN
113 SECTION 14 - GLOSSARY
■ Is generally not useful to a person in the absence of a Sickness, Injury or their symptoms.
■ Can withstand repeated use.
■ Is not implantable within the body.
■ Is appropriate for use, and is primarily used, within the home.
Eligible Expenses - for Covered Health Services, incurred while the Plan is in effect,
Eligible Expenses are determined by UnitedHealthcare as stated below and as detailed in
Section 3, How the Plan Works.
Eligible Expenses are determined solely in accordance with UnitedHealthcare's
reimbursement policy guidelines. UnitedHealthcare develops the reimbursement policy
guidelines, in UnitedHealthcare's discretion, following evaluation and validation of all
provider billings in accordance with one or more of the following methodologies:
■ As indicated in the most recent edition of the Current Procedural Terminology (CPT), a
publication of the American Medical Association, and/or the Centers for Medicare and Medicaid
Services (CMS).
■ As reported by generally recognized professionals or publications.
■ As used for Medicare.
■ As determined by medical staff and outside medical consultants pursuant to other
appropriate source or determination that UnitedHealthcare accept.
Emergency – a medical condition manifesting itself by acute symptoms of sufficient
severity (including severe pain) so that a prudent layperson, who possesses an average
knowledge of health and medicine, could reasonably expect the absence of immediate
medical attention to result in any of the following:
■ Placing the health of the Covered Person (or, with respect to a pregnant woman, the
health of the woman or her unborn child) in serious jeopardy.
■ Serious impairment to bodily functions.
■ Serious dysfunction of any bodily organ or part.
Emergency Health Services – with respect to an Emergency, both of the following:
■ A medical screening examination (as required under section 1867 of the Social Security Act,
42 U.S.C. 1395dd) that is within the capability of the emergency department of a
Hospital, including ancillary services routinely available to the emergency department to
evaluate such Emergency.
■ Such further medical examination and treatment, to the extent they are within the
capabilities of the staff and facilities available at the Hospital, as are required under
section 1867 of the Social Security Act (42 U.S.C. 1395dd(e)(3)).
Employer - City of Denton.
EOB - see Explanation of Benefits (EOB).
CITY OF DENTON GOLD MEDICAL PLAN
114 SECTION 14 - GLOSSARY
Experimental or Investigational Services - medical, surgical, diagnostic, psychiatric,
mental health, substance-related and addictive disorders or other health care services,
technologies, supplies, treatments, procedures, drug therapies, medications or devices that, at
the time the Claims Administrator 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.)
■ 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 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, the Claims Administrator 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, the
Claims Administrator 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.
■ The reason(s) why the service or supply was not covered by the Plan.
Gender Dysphoria - A disorder characterized by the following diagnostic criteria classified
in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric
Association:
CITY OF DENTON GOLD MEDICAL PLAN
115 SECTION 14 - GLOSSARY
■ Diagnostic criteria for adults and adolescents:
- A marked incongruence between one's experienced/expressed gender and assigned
gender, of at least six months' duration, as manifested by at least two of the
following:
♦ A marked incongruence between one's experienced/expressed gender and
primary and/or secondary sex characteristics (or in young adolescents, the
anticipated secondary sex characteristics).
♦ A strong desire to be rid of one's primary and/or secondary sex characteristics
because of a marked incongruence with one's experienced/expressed gender or
in young adolescents, a desire to prevent the development of the anticipated
secondary sex characteristics).
♦ A strong desire for the primary and/or secondary sex characteristics of the other
gender.
♦ A strong desire to be of the other gender (or some alternative gender different
from one's assigned gender).
♦ A strong desire to be treated as the other gender (or some alternative gender
different from one's assigned gender).
♦ A strong conviction that one has the typical feelings and reactions of the other
gender (or some alternative gender different from one's assigned gender).
- The condition is associated with clinically significant distress or impairment in social,
occupational or other important areas of functioning.
■ Diagnostic criteria for children:
- A marked incongruence between one's experienced/expressed gender and assigned
gender, of at least six months' duration, as manifested by at least six of the following
(one of which must be criterion as shown in the first bullet below):
♦ A strong desire to be of the other gender or an insistence that one is the other
gender (or some alternative gender different from one's assigned gender).
♦ In boys (assigned gender), a strong preference for cross-dressing or simulating
female attire; or in girls (assigned gender), a strong preference for wearing only
typical masculine clothing and a strong resistance to the wearing of typical
feminine clothing.
♦ A strong preference for cross-gender roles in make-believe play or fantasy play.
♦ A strong preference for the toys, games or activities stereotypically used or
engaged in by the other gender.
♦ A strong preference for playmates of the other gender.
♦ In boys (assigned gender), a strong rejection of typically masculine toys, games
and activities and a strong avoidance of rough-and-tumble play; or in girls
(assigned gender), a strong rejection of typically feminine toys, games and
activities.
♦ A strong dislike of ones' sexual anatomy.
♦ A strong desire for the primary and/or secondary sex characteristics that match
one's experienced gender.
- The condition is associated with clinically significant distress or impairment in social,
school or other important areas of functioning.
CITY OF DENTON GOLD MEDICAL PLAN
116 SECTION 14 - GLOSSARY
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 and that meets both of the following:
■ It is primarily engaged in providing health services, on an inpatient basis, for the acute
care and treatment of sick or injured individuals. Care is provided through medical,
mental health, substance-related and addictive disorders, diagnostic and surgical facilities,
by or under the supervision of a staff of Physicians.
■ It has 24-hour nursing services.
A Hospital is not primarily a place for rest, Custodial Care or care of the aged and is not a
nursing home, convalescent home or similar institution.
Injury - bodily damage other than Sickness, including all related conditions and recurrent
symptoms.
Inpatient Rehabilitation Facility - a long term acute rehabilitation center, a Hospital (or a
special unit of a Hospital designated as an Inpatient Rehabilitation Facility) that provides
rehabilitation services (including 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 Behavioral Therapy (IBT) – outpatient behavioral/educational services that aim
to reinforce adaptive behaviors, reduce maladaptive behaviors and improve the mastery of
functional age appropriate skills in people with Autism Spectrum Disorders. Examples
include Applied Behavior Analysis (ABA), The Denver Model, and Relationship Development
Intervention (RDI).
Intensive Outpatient Treatment - a structured outpatient mental health or substance-
related and addictive disorders treatment program that may be free-standing or Hospital-
based and provides services for at least three hours per day, two or more days per week.
Intermittent Care - skilled nursing care that is provided or needed either:
■ Fewer than seven days each week.
■ Fewer than eight hours each day for periods of 21 days or less.
Exceptions may be made in special circumstances when the need for additional care is finite
and predictable.
Kidney Resource Services (KRS) - a program administered by UnitedHealthcare or its
affiliates made available to you by City of Denton. The KRS program provides:
CITY OF DENTON GOLD MEDICAL PLAN
117 SECTION 14 - GLOSSARY
■ Specialized consulting services to Participants and enrolled Dependents with ESRD or
chronic kidney disease.
■ Access to dialysis centers with expertise in treating kidney disease.
■ Guidance for the patient on the prescribed plan of care.
Manipulative Treatment - the therapeutic application of chiropractic and/or osteopathic
manipulative treatment with or without ancillary physiologic treatment and/or rehabilitative
methods rendered to restore/improve motion, reduce pain and improve function in the
management of an identifiable neuromusculoskeletal condition.
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 - health care services provided for the purpose of preventing,
evaluating, diagnosing or treating a Sickness, Injury, Mental Illness, substance-related and
addictive disorders, condition, disease or its symptoms, that are all of the following as
determined by the Claims Administrator or its designee, within the Claims Administrator'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 disorders, disease or its symptoms.
■ Not mainly for your convenience or that of your doctor or other health care provider.
■ Not more costly than an alternative drug, service(s) or supply that is at least as likely to
produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of
your Sickness, Injury, disease or symptoms.
Generally Accepted Standards of Medical Practice are standards that are based on credible scientific
evidence published in peer-reviewed medical literature generally recognized by the relevant
medical community, relying primarily on controlled clinical trials, or, if not available,
observational studies from more than one institution that suggest a causal relationship
between the service or treatment and health outcomes.
If no credible scientific evidence is available, then standards that are based on Physician
specialty society recommendations or professional standards of care may be considered. The
Claims Administrator 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 the Claims Administrator's sole discretion.
The Claims Administrator 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 the Claims Administrator and revised from time to time), are
CITY OF DENTON GOLD MEDICAL PLAN
118 SECTION 14 - GLOSSARY
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
www.UnitedHealthcareOnline.com.
Medicare - Parts A, B, C and D of the insurance program established by Title XVIII, United
States Social Security Act, as amended by 42 U.S.C. Sections 1394, et seq. and as later amended.
Mental Health Services - Covered Health Services for the diagnosis and treatment of
Mental Illnesses. The fact that a condition is listed in the current Diagnostic and Statistical
Manual of the American Psychiatric Association does not mean that treatment for the condition is
a Covered Health Service.
Mental Health/Substance-Related and Addictive Disorders Services Administrator –
the organization or individual designated by City of Denton who provides or arranges
Mental Health and Substance-Related and Addictive Disorders Services under the Plan.
Mental Illness - mental health or psychiatric diagnostic categories listed in the current
Diagnostic and Statistical Manual of the American Psychiatric Association, unless they are listed in
Section 8, Exclusions and Limitations.
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. 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 - for Benefit Plans that have a Network Benefit level, this is the
description of how Benefits are paid for Covered Health Services provided by Network
providers. Refer to Section 5, Plan Highlights to determine whether or not your Benefit plan
offers Network Benefits and Section 3, How the Plan Works, for details about how Network
Benefits apply.
Open Enrollment - the period of time, determined by City of Denton, during which eligible
Participants may enroll themselves and their Dependents under the Plan. City of Denton
determines the period of time that is the Open Enrollment period.
Out-of-Pocket Maximum - for Benefit plans that have an Out-of-Pocket Maximum, this is
the maximum amount you pay every calendar year. Refer to Section 5, Plan Highlights for the
CITY OF DENTON GOLD MEDICAL PLAN
119 SECTION 14 - GLOSSARY
Out-of-Pocket Maximum amount. See Section 3, How the Plan 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.
Participant - a full-time Participant of the Employer who meets the eligibility requirements
specified in the Plan, as described under Eligibility in Section 2, Introduction. A Participant
must live and/or work in the United States.
Pharmaceutical Product(s) - U.S. Food and Drug Administration (FDA)-approved
prescription pharmaceutical products administered in connection with a Covered Health
Service by a Physician or other health care provider within the scope of the provider's
license, and not otherwise excluded under the Plan.
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 - The City of Denton Medical Plan.
Plan Administrator - City of Denton or its designee.
Plan Sponsor - City of Denton.
Pregnancy - includes all of the following:
■ Prenatal care.
■ Postnatal care.
■ Childbirth.
■ Any complications associated with the above.
Primary Physician - a Physician who has a majority of his or her practice in general
pediatrics, internal medicine, obstetrics/gynecology, family practice or general medicine.
Private Duty Nursing - nursing care that is provided to a patient on a one-to-one basis by
licensed nurses in an inpatient or a home setting when any of the following are true:
■ No skilled services are identified.
■ Skilled nursing resources are available in the facility.
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120 SECTION 14 - GLOSSARY
■ The skilled care can be provided by a Home Health Agency on a per visit basis for a
specific purpose.
■ The service is provided to a Covered Person by an independent nurse who is hired
directly by the Covered Person or his/her family. This includes nursing services provided
on an inpatient or a home-care basis, whether the service is skilled or non-skilled
independent nursing.
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.
Residential Treatment – treatment in a facility which provides Mental Health Services or
Substance-Related and Addictive Disorders Services treatment. The facility meets all of the
following requirements:
■ It is established and operated in accordance with applicable state law for Residential
Treatment programs.
■ It provides a program of treatment under the active participation and direction of a
Physician and approved by the Mental Health/Substance-Related and Addictive
Disorders Administrator.
■ It has or maintains a written, specific and detailed treatment program requiring full-time
residence and full-time participation by the patient.
■ It provides at least the following basic services in a 24-hour per day, structured milieu:
- Room and board.
- Evaluation and diagnosis.
- Counseling.
- Referral and orientation to specialized community resources.
A Residential Treatment facility that qualifies as a Hospital is considered a Hospital.
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.
Sickness - physical illness, disease or Pregnancy. The term Sickness as used in this SPD
includes Mental Illness or substance-related and addictive disorders, regardless of the cause
or origin of the Mental Illness or substance-related and addictive disorder.
CITY OF DENTON GOLD MEDICAL PLAN
121 SECTION 14 - GLOSSARY
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 dressing, feeding, bathing or transferring from a bed to a chair.
■ They require clinical training in order to be delivered safely and effectively.
■ They are not Custodial Care, as defined in this section.
Skilled Nursing Facility - a Hospital or 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.
Spouse - your spouse.
Substance-Related and Addictive Disorders Services - Covered Health Services for the
diagnosis and treatment of alcoholism and substance-related and addictive disorders that are
listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association, unless
those services are specifically excluded. The fact that a disorder is listed in the Diagnostic and
Statistical Manual of the American Psychiatric Association does not mean that treatment of the
disorder is a Covered Health Service.
Total Disability or Totally Disabled - a Participant's inability to perform all of the
substantial and material duties of his or her regular employment or occupation; and a
Dependent's inability to perform the normal activities of a person of like age and gender.
Transitional Living - Mental Health Services/Substance-Related and Addictive Disorders
Services that are provided through 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.
■ Supervised living arrangements which are residences such as 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
CITY OF DENTON GOLD MEDICAL PLAN
122 SECTION 14 - GLOSSARY
arrangements may be utilized as an adjunct to treatment when treatment doesn't offer
the intensity and structure needed to assist the Covered Person with recovery.
Unproven Services - health services, including medications that are determined not to be
effective for treatment of the medical condition and/or not to have a beneficial effect on
health outcomes due to insufficient and inadequate clinical evidence from well-conducted
randomized controlled trials or cohort studies in the prevailing published peer-reviewed
medical literature.
■ Well-conducted randomized controlled trials 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 from more than one institution 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.
UnitedHealthcare has a process by which it compiles and reviews clinical evidence with
respect to certain health services. From time to time, UnitedHealthcare 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), UnitedHealthcare 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, UnitedHealthcare 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 UnitedHealthcare's discretion. Other apparently similar promising but unproven services
may not qualify.
Urgent Care – care that requires prompt attention to avoid adverse consequences, but does
not pose an immediate threat to a person’s life. Urgent care is usually delivered in a walk-in
setting and without an appointment. Urgent care facilities are a location, distinct from a
hospital emergency department, an office or a clinic. The purpose is to diagnose and treat
illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.
Urgent Care Center – a facility that provides Covered Health Services that are required to
prevent serious deterioration of your health, and that are required as a result of an
unforeseen Sickness, Injury, or the onset of acute or severe symptoms.
CITY OF DENTON GOLD MEDICAL PLAN
123 SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS
SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS
What this section includes:
■ Benefits available for Prescription Drug Products.
■ How to utilize the retail and mail order service for obtaining Prescription Drug
Products.
■ Any Benefit limitations and exclusions that exist for Prescription Drug Products.
■ Definitions of terms used throughout this section related to the Prescription Drug
Product Plan.
Schedule of Benefits
Prescription Drug Product Coverage Highlights
The table below provides an overview of the Plan's Prescription Drug Product coverage. It
includes Copay amounts that apply when you have a prescription filled at a Network
Pharmacy after you meet the Annual Prescription Drug Deductible. For detailed
descriptions of your Benefits, refer to Retail and Mail Order in this section.
Note: An Annual Prescription Drug Deductible of $50 per Covered Person (up to a
maximum of $150 per family) applies to your Network Benefits, which is separate from the
Annual Deductible for your medical coverage. Copays apply toward the Annual Prescription
Drug Deductible.
Coupons: UnitedHealthcare may not permit certain coupons or offers from pharmaceutical
manufacturers to reduce your Copayment and/or Coinsurance or apply to your Annual
Drug Deductible. You may access information on which coupons or offers are not
permitted through the Internet at www.myuhc.com or by calling the number on your ID
card.
Note: The Out-of-Pocket Maximum applies to all Covered Health Services under the Plan,
including Covered Health Services provided in Section 6, Additional Coverage Details.
Coupons: UnitedHealthcare may not permit certain coupons or offers from pharmaceutical
manufacturers to reduce your Copayment and/or Coinsurance or apply to your Annual
Drug Deductible. You may access information on which coupons or offers are not
permitted through the Internet at www.myuhc.com or by calling the number on your ID
card.
If a Brand-name Drug Becomes Available as a Generic
If a Brand-name Prescription Drug Product becomes available as a Generic drug, the tier
placement of the Brand-name Prescription Drug Product may change and an Ancillary
Charge may apply. As a result, your Copay may change. You will pay the Copay applicable
for the tier to which the Prescription Drug Product is assigned.
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124 SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS
Prior Authorization Requirements
Before certain Prescription Drug Products are dispensed to you, it is the responsibility of
your Physician, your pharmacist or you to obtain prior authorization from UnitedHealthcare
or its designee. The reason for obtaining prior authorization from UnitedHealthcare or its
designee is to determine if the Prescription Drug Product, in accordance with
UnitedHealthcare's approved guidelines, is each of the following:
■ It meets the definition of a Covered Health Service as defined by the Plan.
■ It is not an Experimental or Investigational or Unproven Service, as defined in Section
14, Glossary.
The Plan may also require you to obtain prior authorization from UnitedHealthcare or its
designee so UnitedHealthcare can determine whether the Prescription Drug Product, in
accordance with UnitedHealthcare's approved guidelines, was prescribed by a Specialist
Physician.
Network Pharmacy Prior Authorization
When Prescription Drug Products are dispensed at a Network Pharmacy, the prescribing
provider, the pharmacist, or you are responsible for obtaining prior authorization from
UnitedHealthcare.
If you do not obtain prior authorization from UnitedHealthcare before the Prescription
Drug Product is dispensed, you can ask UnitedHealthcare to consider reimbursement after
you receive the Prescription Drug Product. You will be required to pay for the Prescription
Drug Product at the pharmacy. You may seek reimbursement from the Plan as described in
Section 9, Claims Procedures.
When you submit a claim on this basis, you may pay more because you did not obtain prior
authorization from UnitedHealthcare before the Prescription Drug Product was dispensed.
The amount you are reimbursed will be based on the Prescription Drug Charge (for
Prescription Drug Products from a Network Pharmacy), less the required Copayment
and/or Coinsurance, Ancillary Charge and any Deductible that applies.
To determine if a Prescription Drug Product requires prior authorization, either visit
www.myuhc.com or call the number on your ID card. The Prescription Drug Products
requiring prior authorization are subject to UnitedHealthcare's periodic review and
modification.
Benefits may not be available for the Prescription Drug Product after UnitedHealthcare
reviews the documentation provided and determines that the Prescription Drug Product is
not a Covered Health Service or it is an Experimental or Investigational or Unproven
Service.
UnitedHealthcare may also require prior authorization for certain programs which may have
specific requirements for participation and/or activation of an enhanced level of Benefits
associated with such programs. You may access information on available programs and any
applicable prior authorization, participation or activation requirements associated with such
CITY OF DENTON GOLD MEDICAL PLAN
125 SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS
programs through the Internet at www.myuhc.com or by calling the number on your ID
card.
Covered Health Services1,2 Your Cost Sharing Amount:
Retail - As written by the provider, up to a
consecutive 30-day supply of a
Prescription Drug Product, unless adjusted
based on the drug manufacturer's
packaging size, or based on supply limits.3
■ Tier-1 $10 Copay
■ Tier-2 $40 Copay after you meet the Prescription
Drug Deductible
■ Tier-3 $60 Copay after you meet the Prescription
Drug Deductible
Specialty Prescription Drug Products -
As written by the provider, up to a
consecutive 30-day supply of a Specialty
Prescription Drug Product, unless adjusted
based on the drug manufacturer's
packaging size, or based on supply limits.
$125 or 20% of the Prescription Drug Cost,
whichever is less, after you meet the
Prescription Drug Deductible
Supply limits apply to Specialty
Prescription Drug Products obtained at a
Network Pharmacy, a mail order Network
Pharmacy or a Designated Pharmacy.
Mail Order - up to a 90-day supply3
■ Tier-1 $20 Copay
■ Tier-2 $100 Copay after you meet the Prescription
Drug Deductible
■ Tier-3 $150 Copay after you meet the Prescription
Drug Deductible
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126 SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS
Covered Health Services1,2 Your Cost Sharing Amount:
The plan will allow one 90-day supply per calendar year of prescription smoking cessation
drugs which are included on the Prescription Drug List at 100%, not subject to a
Copayment.
Insulin products which are included in the Prescription Drug List and diabetic supplies
purchased at the same time as the insulin are covered at 100% and are not subject to a
Copayment.
1You, your Physician or your pharmacist must obtain prior authorization from UnitedHealthcare to
receive full Benefits for certain Prescription Drug Products. Otherwise, you may pay more out-of-
pocket. See Prior Authorization Requirements in this section for details.
2You are not responsible for paying a Copayment and/or Coinsurance for Preventive Care
Medications. Benefits for Preventive Care Medications are not subject to payment of the Annual
Prescription Drug Products Deductible.
3These supply limits do not apply to Specialty Prescription Drug Products. Specialty Prescription
Drug Products from a mail order Network Pharmacy are subject to the supply limits stated above
under the heading Specialty Prescription Drug Products.
Note: The Coordination of Benefits provision described in Section 10, Coordination of Benefits
(COB) applies to covered Prescription Drug Products as described in this section. Benefits
for Prescription Drug Products will be coordinated with those of any other health plan in
the same manner as Benefits for Covered Health Services described in this SPD.
Identification Card (ID Card) - Network Pharmacy
You must either show your ID card at the time you obtain your Prescription Drug Product
at a Network Pharmacy or you must provide the Network Pharmacy with identifying
information that can be verified by UnitedHealthcare during regular business hours.
If you don't show your ID card or provide verifiable information at a Network Pharmacy,
you will be required to pay the Usual and Customary Charge for the Prescription Drug at the
pharmacy.
You may seek reimbursement from the Plan as described in Section 9, Claims Procedures,
under the heading, How to File a Claim. When you submit a claim on this basis, you may pay
more because you failed to verify your eligibility when the Prescription Drug Product was
dispensed. The amount you are reimbursed will be based on the Prescription Drug Charge,
less the required Copayment and/or Coinsurance, Ancillary Charge, and any deductible that
applies.
CITY OF DENTON GOLD MEDICAL PLAN
127 SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS
Submit your claim to:
Optum Rx
P.O. Box 29077
Hot Springs, AR 71903
Benefit Levels
Benefits are available for outpatient Prescription Drug Products that are considered Covered
Health Services.
The Plan pays Benefits at different levels for for tier-1, tier-2 and tier-3 Prescription Drug
Products. All Prescription Drug Products covered by the Plan are categorized into these
three tiers on the Prescription Drug List (PDL). The tier status of a Prescription Drug
Product can change periodically, generally quarterly but no more than six times per calendar
year, based on the Prescription Drug List Management Committee's periodic tiering
decisions. When that occurs, you may pay more or less for a Prescription Drug Product,
depending on its tier assignment. Since the PDL may change periodically, you can visit
www.myuhc.com or call UnitedHealthcare at the number on your ID card for the most
current information.
Each tier is assigned a Copay, which is the amount you pay after you have met the Annual
Prescription Drug Deductible, when you visit the pharmacy or order your medications
through mail order. Your Copay will also depend on whether or not you visit the pharmacy
or use the mail order service - see the table shown at the beginning of this section for further
details. Here's how the tier system works:
■ Tier-1 is your lowest Copay option. For the lowest out-of-pocket expense, you should
consider tier-1 drugs if you and your Physician decide they are appropriate for your
treatment.
■ Tier-2 is your middle Copay option. Consider a tier-2 drug if no tier-1 drug is available to
treat your condition.
■ Tier-3 is your highest Copay option. The drugs in tier-3 are usually more costly.
Sometimes there are alternatives available in tier-1 or tier-2.
Coinsurance for a Prescription Drug at a Network Pharmacy is a percentage of the
Prescription Drug Charge.
For Prescription Drug Products at a retail Network Pharmacy, you are responsible for
paying the lower of:
■ The applicable Copay and/or Coinsurance.
■ The Network Pharmacy's Usual and Customary Charge for the Prescription Drug.
■ The Prescription Drug Charge that UnitedHealthcare agreed to pay the Network
Pharmacy.
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128 SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS
For Prescription Drug Products from a mail order Network Pharmacy, you are responsible
for paying the lower of:
■ The applicable Copay and/or Coinsurance.
■ The Prescription Drug Charge for that particular Prescription Drug.
Retail
The Plan has a Network of participating retail pharmacies, which includes many large drug
store chains. You can obtain information about Network Pharmacies by contacting
UnitedHealthcare at the number on your ID card or by logging onto www.myuhc.com.
To obtain your prescription from a Network pharmacy, simply present your ID card and pay
the Copay, after meeting the Annual Prescription Drug Deductible. The Plan pays Benefits
for certain covered Prescription Drug Products:
■ As written by a Physician.
■ Up to a consecutive 31-day supply, unless adjusted based on the drug manufacturer's
packaging size or based on supply limits.
■ When a Prescription Drug is packaged or designed to deliver in a manner that provides
more than a consecutive 31-day supply, the Copay that applies will reflect the number of
days dispensed.
■ A one-cycle supply of an oral contraceptive. You may obtain up to three cycles at one
time if you pay the Copay for each cycle supplied.
If you purchase a Prescription Drug from a non-Network Pharmacy, you will be required to
pay full price and will not receive reimbursement under the Plan.
Note: Network Pharmacy Benefits apply only if your prescription is for a Covered Health
Service, and not for Experimental or Investigational, or Unproven Services. Otherwise, you
are responsible for paying 100% of the cost.
Mail Order
The mail order service may allow you to purchase up to a 90-day supply of a covered
maintenance drug through the mail from a Network Pharmacy . Maintenance drugs help in
the treatment of chronic illnesses, such as heart conditions, allergies, high blood pressure,
and arthritis.
To use the mail order service, all you need to do is complete a patient profile and enclose
your Prescription Order or Refill. Your medication, plus instructions for obtaining refills,
will arrive by mail about 14 days after your order is received. If you need a patient profile
form, or if you have any questions, you can reach UnitedHealthcare at the number on your
ID card.
CITY OF DENTON GOLD MEDICAL PLAN
129 SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS
The Plan pays mail order Benefits for certain covered Prescription Drug Products:
■ As written by a Physician.
■ Up to a consecutive 90-day supply, unless adjusted based on the drug manufacturer's
packaging size or based on supply limits.
These supply limits do not apply to Specialty Prescription Drug Products. Specialty
Prescription Drug Products from a mail order Network Pharmacy are subject to the supply
limits stated above under the heading Specialty Prescription Drug Products.
You may be required to fill an initial Prescription Drug Product order and obtain one refill
through a retail pharmacy prior to using a mail order Network Pharmacy.
Note: To maximize your Benefit, ask your Physician to write your Prescription Order or
Refill for a 90-day supply, with refills when appropriate. You will be charged a mail order
Copay for any Prescription Order or Refill if you use the mail order service, regardless of the
number of days' supply that is written on the order or refill. Be sure your Physician writes
your mail order or refill for a 90-day supply, not a 30-day supply with three refills.
Benefits for Preventive Care Medications
Benefits under the Prescription Drug Plan include those for Preventive Care Medications as
defined, in this section, under Glossary - Prescription Drug Products. You may determine whether
a drug is a Preventive Care Medication through the internet at www.myuhc.com or by
calling UnitedHealthcare at the number on your ID card.
Designated Pharmacies
If you require certain Prescription Drug Products, including, but not limited to, Specialty
Prescription Drug Products, UnitedHealthcare may direct you to a Designated Pharmacy
with whom it has an arrangement to provide those Prescription Drug Products.
If you are directed to a Designated Pharmacy and you choose not to obtain your
Prescription Drug Product from a Designated Pharmacy, you will be subject to the Non-
Network Benefit for that Prescription Drug Product.
Specialty Prescription Drug Products
You may fill a prescription for Specialty Prescription Drug Products up to one time at any
Network Pharmacy. However, after that you will be directed to a Designated Pharmacy and
if you choose not to obtain your Specialty Prescription Drug Products from a Designated
Pharmacy, no Benefits will be paid and you will be responsible for paying all charges.
Please see the Prescription Drug Glossary in this section for definitions of Specialty
Prescription Drug and Designated Pharmacy. Refer to the tables at the beginning of this
section for details on Specialty Prescription Drug supply limits.
CITY OF DENTON GOLD MEDICAL PLAN
130 SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS
Want to lower your out-of-pocket Prescription Drug costs?
Consider tier-1 Prescription Drug Products, if you and your Physician decide they are
appropriate.
Assigning Prescription Drug Products to the PDL
UnitedHealthcare's Prescription Drug List (PDL) Management Committee is authorized to
make tier placement changes on UnitedHealthcare's behalf. The PDL Management
Committee makes the final classification of an FDA-approved Prescription Drug Product to
a certain tier by considering a number of factors including, but not limited to clinical and
economic factors. Clinical factors may include, but are not limited to, evaluations of the
place in therapy, relative safety or relative efficacy of the Prescription Drug Product, as well
as whether certain supply limits or prior authorization requirements should apply. Economic
factors may include, but are not limited to, the Prescription Drug Product's acquisition cost
including, but not limited to, available rebates and assessments on the cost effectiveness of
the Prescription Drug Product.
Some Prescription Drug Products are most cost effective for specific indications as
compared to others, therefore, a Prescription Drug Product may be listed on multiple tiers
according to the indication for which the Prescription Drug Product was prescribed, or
according to whether it was prescribed by a Specialist Physician.
The PDL Management Committee may periodically change the placement of a Prescription
Drug Product among the tiers. These changes generally will occur quarterly, but no more
than six times per calendar year. These changes may occur without prior notice to you.
When considering a Prescription Drug Product for tier placement, the PDL Management
Committee reviews clinical and economic factors regarding Covered Persons as a general
population. Whether a particular Prescription Drug Product is appropriate for an individual
Covered Person is a determination that is made by the Covered Person and the prescribing
Physician.
Note: The tier status of a Prescription Drug Product may change periodically based on the
process described above. As a result of such changes, you may be required to pay more or
less for that Prescription Drug Product. Please access www.myuhc.com through the
Internet or call the number on your ID card for the most up-to-date tier status.
Prescription Drug, Prescription Drug List (PDL), and Prescription Drug List (PDL)
Management Committee are defined at the end of this section.
Prescription Drug List (PDL)
The Prescription Drug List (PDL) is a tool that helps guide you and your Physician in
choosing the medications that allow the most effective and affordable use of your
Prescription Drug Benefit.
Prescription Drug Benefit Claims
For Prescription Drug Product claims procedures, please refer to Section 9, Claims Procedures.
CITY OF DENTON GOLD MEDICAL PLAN
131 SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS
Limitation on Selection of Pharmacies
If UnitedHealthcare determines that you may be using Prescription Drug Products in a
harmful or abusive manner, or with harmful frequency, your selection of Network
Pharmacies may be limited. If this happens, UnitedHealthcare may require you to select a
single Network Pharmacy that will provide and coordinate all future pharmacy services.
Benefits will be paid only if you use the designated single Network Pharmacy. If you don't
make a selection within 31 days of the date the Plan Administrator notifies you,
UnitedHealthcare will select a single Network Pharmacy for you.
Supply Limits
Benefits for Prescription Drug Products are subject to supply limits that are stated in the
table under the heading Prescription Drug Product Coverage Highlights. For a single Copayment
and/or Coinsurance, you may receive a Prescription Drug Product up to the stated supply
limit. Whether or not a Prescription Drug Product has a supply limit is subject to
UnitedHealthcare's periodic review and modification.
Note: Some products are subject to additional supply limits based on criteria that the Plan
Administrator and UnitedHealthcare have developed, subject to periodic review and
modification. The limit may restrict the amount dispensed per Prescription Order or Refill
and/or the amount dispensed per month's supply.
Prescription Drug Products that are Chemically Equivalent
If two drugs are Chemically Equivalent (they contain the same active ingredient) and you or
your Physician choose not to substitute a lower tiered drug for the higher tiered drug, you
will pay the difference between the higher tiered drug and the lower tiered drug, in addition
to the lower tiered drug's Copayment. This difference in cost is called an Ancillary Charge.
An Ancillary Charge may apply when a covered Prescription Drug Product is dispensed at
your or the provider's request and there is another drug that is chemically the same available
at a lower tier. An Ancillary Charge does not apply to any Out-of-Pocket Maximum.
Special Programs
City of Denton and UnitedHealthcare may have certain programs in which you may receive
an enhanced or reduced Benefit based on your actions such as adherence/compliance to
medication or treatment regimens and/or participation in health management programs.
You may access information on these programs through the Internet at www.myuhc.com
or by calling the number on the back of your ID card.
Prescription Drug Products Prescribed by a Specialist Physician
You may receive an enhanced or reduced Benefit, or no Benefit, based on whether the
Prescription Drug Product was prescribed by a Specialist Physician. You may access
information on which Prescription Drug Products are subject to Benefit enhancement,
reduction or no Benefit through the Internet at www.myuhc.com or by calling the number
on your ID card.
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132 SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS
Rebates and Other Discounts
UnitedHealthcare and City of Denton may, at times, receive rebates for certain drugs on the
PDL, including those drugs that you purchase prior to meeting your Annual Drug
Deductible. UnitedHealthcare does not pass these rebates on to you, nor are they applied to
the Annual Drug Deductible or taken into account in determining your Copays.
UnitedHealthcare and a number of its affiliated entities, conduct business with various
pharmaceutical manufacturers separate and apart from this Outpatient Prescription Drug section.
Such business may include, but is not limited to, data collection, consulting, educational
grants and research. Amounts received from pharmaceutical manufacturers pursuant to such
arrangements are not related to this Outpatient Prescription Drug section. UnitedHealthcare is
not required to pass on to you, and does not pass on to you, such amounts.
Coupons, Incentives and Other Communications
At various times, UnitedHealthcare may send mailings or provide other communications to
you, your Physician or your pharmacy that communicate a variety of messages, including
information about Prescription Drug Products. These communications may include offers
that enable you, at your discretion, to purchase the described product at a discount. In some
instances, non-UnitedHealthcare entities may support and/or provide content for these
communications and offers. Only you and your Physician can determine whether a change in
your Prescription and/or non-prescription Drug regimen is appropriate for your medical
condition.
Exclusions - What the Prescription Drug Plan Will Not Cover
Exclusions from coverage listed in Section 8, Exclusions and Limitations also apply to this
section. In addition, the exclusions listed below apply.
When an exclusion applies to only certain Prescription Drug Products, you can access
www.myuhc.com through the Internet or by calling the number on your ID card for
information on which Prescription Drug Products are excluded.
Medications that are:
1. For any condition, Injury, Sickness or mental illness arising out of, or in the course of,
employment for which benefits are available under any workers' compensation law or
other similar laws, whether or not a claim for such benefits is made or payment or
benefits are received.
2. Any Prescription Drug Product for which payment or benefits are provided or available
from the local, state or federal government (for example Medicare) whether or not
payment or benefits are received, except as otherwise provided by law.
3. Pharmaceutical Products for which Benefits are provided in the medical (not in Section
15, Outpatient Prescription Drugs) portion of the Plan.
This exclusion does not apply to Depo Provera and other injectable drugs used for
contraception.
CITY OF DENTON GOLD MEDICAL PLAN
133 SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS
4. Available over-the-counter that do not require a Prescription Order or Refill by federal
or state law before being dispensed, unless the Plan Administrator has designated over-
the-counter medication as eligible for coverage as if it were a Prescription Drug Product
and it is obtained with a Prescription Order or Refill from a Physician. Prescription Drug
Products that are available in over-the-counter form or comprised of components that
are available in over-the-counter form or equivalent. Certain Prescription Drug Products
that the Plan Administrator has determined are Therapeutically Equivalent to an over-
the-counter drug. Such determinations may be made up to six times during a calendar
year, and the Plan Administrator may decide at any time to reinstate Benefits for a
Prescription Drug Product that was previously excluded under this provision.
5. Compounded drugs that contain certain bulk chemicals. (Compounded drugs that
contain at least one ingredient that requires a Prescription Order or Refill are assigned to
Tier-3.) Compounded drugs that are available as a similar commercially available
Prescription Drug Product.
6. Dispensed by a non-Network Pharmacy.
7. Dispensed outside of the United States, except in an Emergency.
8. Durable Medical Equipment (prescribed and non-prescribed outpatient supplies, other
than the diabetic supplies and inhaler spacers specifically stated as covered).
9. Growth hormone for children with familial short stature (short stature based upon
heredity and not caused by a diagnosed medical condition).
10. The amount dispensed (days' supply or quantity limit) which exceeds the supply limit.
11. The amount dispensed (days' supply or quantity limit) which is less than the minimum
supply limit.
12. Certain Prescription Drug Products that have not been prescribed by a specialist
physician.
13. Certain New Prescription Drug Products until they are reviewed and assigned to a tier by
the PDL Management Committee.
14. Prescribed, dispensed or intended for use during an Inpatient Stay.
15. Prescribed for appetite suppression, and other weight loss products.
16. Prescribed to treat infertility.
17. Prescription Drug Products, including new Prescription Drug Products or new dosage
forms, that UnitedHealthcare and City of Denton determines do not meet the definition
of a Covered Health Service.
18. Prescription Drug Products that contain (an) active ingredient(s) available in and
Therapeutically Equivalent to another covered Prescription Drug Product.
CITY OF DENTON GOLD MEDICAL PLAN
134 SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS
19. Prescription Drug Products that contain (an) active ingredient(s) which is (are) a
modified version of and Therapeutically Equivalent to another covered Prescription
Drug Product.
20. Typically administered by a qualified provider or licensed health professional in an
outpatient setting. (This exclusion does not apply to Depo Provera and other injectable
drugs used for contraception.)
21. Unit dose packaging of Prescription Drug Products.
22. Used for conditions and/or at dosages determined to be Experimental or
Investigational, or Unproven, unless UnitedHealthcare and City of Denton have agreed
to cover an Experimental or Investigational or Unproven treatment, as defined in
Section 14, Glossary.
23. Medications used for cosmetic purposes
24. Prescription Drug Product as a replacement for a previously dispensed Prescription
Drug that was lost, stolen, broken or destroyed.
25. General vitamins, except for the following which require a Prescription Order or Refill:
- Vitamins with fluoride.
- Single entity vitamins.
26. Any product for which the primary use is a source of nutrition, nutritional supplements,
or dietary management of disease, and prescription medical food products even when
used for the treatment of Sickness or Injury.
27. A Prescription Drug Product that contains marijuana, including medical marijuana.
28. Dental products, including but not limited to prescription fluoride topicals.
Glossary - Outpatient Prescription Drugs
Ancillary Charge - a charge, in addition to the Copayment and/or Coinsurance, that you
are required to pay when a covered Prescription Drug Product is dispensed at your or the
provider's request, when a Chemically Equivalent Prescription Drug Product is available on a
lower tier. For Prescription Drug Products from Network Pharmacies, the Ancillary Charge
is calculated as the difference between the Prescription Drug Product Charge or Maximum
Allowable Cost (MAC) List price for Network Pharmacies for the Prescription Drug
Product on the higher tier, and the Prescription Drug Product Charge or Maximum
Allowable Cost (MAC) List price of the Chemically Equivalent Prescription Drug Product
available on the lower tier.
Annual Drug Deductible (or Prescription Drug Deductible) - the amount that you are
required to pay for covered Prescription Drug Products in a calendar year before the Plan
begins paying for Prescription Drug Products. The Annual Prescription Drug Deductible is
shown in the table at the beginning of this section.
CITY OF DENTON GOLD MEDICAL PLAN
135 SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS
Brand-name - a Prescription Drug Product: (1) which is manufactured and marketed under
a trademark or name by a specific drug manufacturer; or (2) that UnitedHealthcare identifies
as a Brand-name product, based on available data resources including, but not limited to,
Medi-Span, that classify drugs as either brand or generic based on a number of factors. You
should know that all products identified as a "brand name" by the manufacturer, pharmacy,
or your Physician may not be classified as Brand-name by UnitedHealthcare.
Chemically Equivalent - when Prescription Drug Products contain the same active
ingredient.
Designated Pharmacy - a pharmacy that has entered into an agreement with
UnitedHealthcare or with an organization contracting on its behalf, to provide specific
Prescription Drug Products including, but not limited to, Specialty Prescription Drug
Products. The fact that a pharmacy is a Network Pharmacy does not mean that it is a
Designated Pharmacy.
Generic - a Prescription Drug Product: (1) that is Chemically Equivalent to a Brand-name
drug; or (2) that UnitedHealthcare identifies as a Generic product based on available data
resources including, but not limited to, Medi-Span, that classify drugs as either brand or
generic based on a number of factors. You should know that all products identified as a
"generic" by the manufacturer, pharmacy or your Physician may not be classified as a
Generic by UnitedHealthcare.
Maximum Allowable Amount - the maximum amount that should be paid for covered
Prescription Drug Products in a Therapeutic Class. This amount is subject to our periodic
review and modification and varies by Therapeutic Class.
Maximum Allowable Cost (MAC) List - a list of Generic Prescription Drug Products that
will be covered at a price level that UnitedHealthcare establishes. This list is subject to
UnitedHealthcare's periodic review and modification.
Network Pharmacy - a pharmacy that has:
■ Entered into an agreement with UnitedHealthcare or an organization contracting on its
behalf to provide Prescription Drug Products to Covered Persons.
■ Agreed to accept specified reimbursement rates for dispensing Prescription Drug
Products.
■ Been designated by UnitedHealthcare as a Network Pharmacy.
New Prescription Drug Product - a Prescription Drug Product or new dosage form of a
previously approved Prescription Drug Product, for the period of time starting on the date
the Prescription Drug Product or new dosage form is approved by the U.S. Food and Drug
Administration (FDA) and ending on the earlier of the following dates:
■ The date it is assigned to a tier by UnitedHealthcare's PDL Management Committee.
■ December 31st of the following calendar year.
CITY OF DENTON GOLD MEDICAL PLAN
136 SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS
PDL - see Prescription Drug List (PDL).
PDL Management Committee - see Prescription Drug List (PDL) Management
Committee.
Predominant Reimbursement Rate - the amount the Plan will pay to reimburse you for a
Prescription Drug Product that is dispensed at a non-Network Pharmacy. The Predominant
Reimbursement Rate for a particular Prescription Drug Product dispensed at a non-Network
Pharmacy includes a dispensing fee and any applicable sales tax. UnitedHealthcare calculates
the Predominant Reimbursement Rate using its Prescription Drug Charge that applies for
that particular Prescription Drug Product at most Network Pharmacies.
Prescription Drug Charge - the rate UnitedHealthcare has agreed to pay its Network
Pharmacies, including the applicable dispensing fee and any applicable sales tax, for a
Prescription Drug dispensed at a Network Pharmacy.
Prescription Drug List (PDL) - a list that categorizes into tiers medications, products or
devices that have been approved by the U.S. Food and Drug Administration. This list is subject
to UnitedHealthcare's periodic review and modification (generally quarterly, but no more
than six times per calendar year). You may determine to which tier a particular Prescription
Drug Product has been assigned by contacting UnitedHealthcare at the number on your ID
card or by logging onto www.myuhc.com.
Prescription Drug List (PDL) Management Committee - the committee that
UnitedHealthcare designates for, among other responsibilities, classifying Prescription Drug
Products into specific tiers.
Prescription Drug Product - a medication, product or device that has been approved by
the U.S. Food and Drug Administration (FDA) and that can, under federal or state law, be
dispensed only pursuant to a Prescription Order or Refill. A Prescription Drug Product
includes a medication that, due to its characteristics, is appropriate for self-administration or
administration by a non-skilled caregiver. For purposes of Benefits under this Plan, this
definition includes:
■ Inhalers (with spacers).
■ Insulin.
■ The following diabetic supplies:
- Standard insulin syringes with needles.
- Blood-testing strips - glucose.
- Urine-testing strips - glucose.
- Ketone-testing strips and tablets.
- Lancets and lancet devices.
- Glucose monitors.
Prescription Order or Refill - the directive to dispense a Prescription Drug Product issued
by a duly licensed health care provider whose scope of practice permits issuing such a
directive.
CITY OF DENTON GOLD MEDICAL PLAN
137 SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS
Preventive Care Medications - the medications that are obtained at a Network Pharmacy
with a Prescription Order or Refill from a Physician and that are payable at 100% of the
Prescription Drug Charge (without application of any Copayment, Coinsurance, Annual
Deductible, Annual Drug Deductible or Specialty Prescription Drug Product Annual
Deductible) as required by applicable law under any of the following:
■ Evidence-based items or services that have in effect a rating of "A" or "B" in the current
recommendations of the United States Preventive Services Task Force.
■ With respect to infants, children and adolescents, evidence-informed preventive care and
screenings provided for in the comprehensive guidelines supported by the Health
Resources and Services Administration.
■ With respect to women, such additional preventive care and screenings as provided for
in comprehensive guidelines supported by the Health Resources and Services Administration.
You may determine whether a drug is a Preventive Care Medication through the internet at
www.myuhc.com or by calling UnitedHealthcare at the number on your ID card.
Specialty Prescription Drug Product - Prescription Drug Products that are generally high
cost, self-administered biotechnology drugs used to treat patients with certain illnesses. You
may access a complete list of Specialty Prescription Drug Products through the Internet at
www.myuhc.com or by calling the number on your ID card.
Therapeutically Equivalent - when Prescription Drug Products have essentially the same
efficacy and adverse effect profile.
Usual and Customary Charge - the usual fee that a pharmacy charges individuals for a
Prescription Drug Product without reference to reimbursement to the pharmacy by third
parties. The Usual and Customary Charge includes a dispensing fee and any applicable sales
tax.
CITY OF DENTON GOLD MEDICAL PLAN
138 SECTION 16 – IMPORTANT ADMINISTRATIVE INFORMATION
SECTION 16 - IMPORTANT ADMINISTRATIVE INFORMATION:
What this section includes:
■ Plan administrative information.
This section includes information on the administration of the medical Plan. While you may
not need this information for your day-to-day participation, it is information you may find
important.
Additional Plan Description
Claims Administrator: The company which provides certain administrative services for the
Plan Benefits described in this Summary Plan Description.
United Healthcare Services, Inc.
9900 Bren Road East
Minnetonka, MN 55343
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.
Type of Administration of the Plan: The Plan Sponsor provides certain administrative
services in connection with its Plan. The Plan Sponsor may, from time to time in its sole
discretion, contract with outside parties to arrange for the provision of other administrative
services including arrangement of access to a Network Provider; claims processing services,
including coordination of benefits and subrogation; utilization management and complaint
resolution assistance. This external administrator is referred to as the Claims Administrator.
For Benefits as described in this Summary Plan Description, the Plan Sponsor also has
selected a provider network established by UnitedHealthcare Insurance Company. The
named fiduciary of Plan is City of Denton, the Plan Sponsor.
The Plan Sponsor retains all fiduciary responsibilities with respect to the Plan except to the
extent the Plan Sponsor has delegated or allocated to other persons or entities one or more
fiduciary responsibility with respect to the Plan.
CITY OF DENTON GOLD MEDICAL PLAN
139 ATTACHMENT I - HEALTH CARE REFORM NOTICES
ATTACHMENT I - HEALTH CARE REFORM NOTICES
Patient Protection and Affordable Care Act ("PPACA")
Patient Protection Notices
The Claims Administrator generally allows the designation of a primary care provider. You
have the right to designate any primary care provider who participates in the Claims
Administrator'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 the Claims Administrator 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 the Claims Administrator 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 the Claims Administrator'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 the Claims Administrator at the number on the back of your ID card.
CITY OF DENTON GOLD MEDICAL PLAN
140 ATTACHMENT II - WHCRA & NMHPA NOTICES
ATTACHMENT II - LEGAL NOTICES
Women's Health and Cancer Rights Act of 1998
As required by the Women's Health and Cancer Rights Act of 1998, the Plan provides Benefits
under the Plan for mastectomy, including reconstruction and surgery to achieve symmetry
between the breasts, prostheses, and complications resulting from a mastectomy (including
lymphedema).
If you are receiving Benefits in connection with a mastectomy, Benefits are also provided for
the following Covered Health Services, as you determine appropriate with your attending
Physician:
■ All stages of reconstruction of the breast on which the mastectomy was performed.
■ Surgery and reconstruction of the other breast to produce a symmetrical appearance.
■ Prostheses and treatment of physical complications of the mastectomy, including
lymphedema.
The amount you must pay for such Covered Health Services (including Copayments and any
Annual Deductible) are the same as are required for any other Covered Health Service.
Limitations on Benefits are the same as for any other Covered Health Service.
Statement of Rights under the Newborns' and Mothers' Health Protection Act
Under Federal law, group health Plans and health insurance issuers offering group health
insurance coverage generally may not restrict Benefits for any Hospital length of stay in
connection with childbirth for the mother or newborn child to less than 48 hours following
a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However,
the Plan or issuer may pay for a shorter stay if the attending provider (e.g., your physician,
nurse midwife, or physician assistant), after consultation with the mother, discharges the
mother or newborn earlier.
Also, under Federal law, plans and issuers may not set the level of Benefits or out-of-pocket
costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less
favorable to the mother or newborn than any earlier portion of the stay.
In addition, a plan or issuer may not, under Federal law, require that a physician or other
health care provider obtain authorization for prescribing a length of stay of up to 48 hours
(or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket
costs, you may be required to obtain prior authorization or notify the Claims Administrator.
For information on notification or prior authorization, contact your issuer.
CITY OF DENTON GOLD MEDICAL PLAN
1 ATTACHMENT III – NONDISCRIMINATION
ATTACHMENT III – NONDISCRIMINATION AND ACCESSIBILITY
REQUIREMENTS
When the Plan uses the words "Claims Administrator" in this Attachment, it is a reference to
United HealthCare Services, Inc., on behalf of itself and its affiliated companies.
The Claims Administrator on behalf of itself and its affiliated companies complies with
applicable Federal civil rights laws and does not discriminate on the basis of race, color,
national origin, age, disability, or sex. UnitedHealthcare does not exclude people or treat
them differently because of race, color, national origin, age, disability, or sex.
The Claims Administrator provides free aids and services to people with disabilities to
communicate effectively with us, such as:
■ Qualified sign language interpreters
■ Written information in other formats (large print, audio, accessible electronic formats,
other formats)
■ Provides free language services to people whose primary language is not English, such
as: Qualified interpreters
■ Information written in other languages
If you need these services, please call the toll-free member number on your health plan ID
card, TTY 711 or the Plan Sponsor.
If you believe that the Claims Administrator has failed to provide these services or
discriminated in another way on the basis of race, color, national origin, age, disability, or
sex, you can file a grievance in writing by mail or email with the Civil Rights Coordinator
identified below. A grievance must be sent within 60 calendar days of the date that you
become aware of the discriminatory action and contain the name and address of the person
filing it along with the problem and the requested remedy.
A written decision will be sent to you within 30 calendar days. If you disagree with the
decision, you may file an appeal within 15 calendar days of receiving the decision.
Claims Administrator Civil Rights Coordinator
United HealthCare Services, Inc. Civil Rights Coordinator
UnitedHealthcare Civil Rights Grievance
P.O. Box 30608
Salt Lake City, UT 84130
The toll-free member phone number listed on your health plan ID card, TTY 711
UHC_Civil_Rights@UHC.com
If you need help filing a grievance, the Civil Rights Coordinator identified above is available
to help you.
CITY OF DENTON GOLD MEDICAL PLAN
2 ATTACHMENT III – NONDISCRIMINATION
You can also file a complaint directly with the U.S. Dept. of Health and Human services
online, by phone or mail:
Online https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD)
Mail: U.S. Dept. of Health and Human Services, 200 Independence Avenue, SW Room
509F, HHH Building, Washington, D.C. 20201
CITY OF DENTON GOLD MEDICAL PLAN
1 ATTACHMENT IV – GETTING HELP IN OTHER LANGUAGES OR FORMATS
ATTACHMENT IV – GETTING HELP IN OTHER LANGUAGES OR FORMATS
You have the right to get help and information in your language at no cost. To request an
interpreter, call the toll-free member phone number listed on your health plan ID card, press
0. TTY 711.
This letter is also available in other formats like large print. To request the document in
another format, please call the toll-free member phone number listed on your health plan ID
card, press 0. TTY 711, Monday through Friday, 8 a.m. to 8 p.m.
Language Translated Taglines
1. Albanian
Ju keni të drejtë të merrni ndihmë dhe informacion falas në gjuhën
tuaj. Për të kërkuar një përkthyes, telefononi në numrin që gjendet në
kartën e planit tuaj shëndetësor, shtypni 0. TTY 711.
2. Amharic ያለ ምንም ክፍያ በቋንቋዎ እርዳታና መረጃ የማግኘት መብት አላችሁ። አስተርጓሚ
እንዲቀርብልዎ ከፈለጉ በጤና ፕላን መታወቂያዎት ላይ ባለው በተጻ መስመር ስልክ
ቁጥር ይደውሉና 0ን ይጫኑ። TTY 711
3. Arabic بلطل .ةفلكت يأ لمحت نود كتغلب تامولعملاو ةدعاسملا ىلع لوصحلا يف قحلا كل
م ةقاطبب جردملا ءاضعلأاب صاخلا يناجملا فتاهلا مقرب لصتا ،يروف مجرتم فّرع
ةيحصلا كتطخب ةصاخلا ةيوضعلا ىلع طغضاو ،0( يصنلا فتاهلا .TTY )711
4. Armenian Թարգմանիչ պահանջէլու համար, զանգահարե՛ք Ձեր
առողջապահական ծրագրի ինքնության (ID) տոմսի վրա
նշված անվճար Անդամնէրի հէռախոսահամարով, սեղմե՛ք
0։ TTY 711
5. Bantu-Kirundi Urafise uburenganzira bwo kuronka ubufasha n’amakuru mu rurimi
rwawe ku buntu. Kugira usabe umusemuzi, hamagara inomero ya
telephone y’ubuntu yagenewe abanywanyi iri ku rutonde ku
karangamuntu k’umugambi wawe w’ubuzima, fyonda 0. TTY 711
6. Bisayan-Visayan
(Cebuano)
Aduna kay katungod nga mangayo og tabang ug impormasyon sa
imong lengguwahe nga walay bayad. Aron mohangyo og tighubad,
tawag sa toll-free nga numero sa telepono sa miyembro nga nakalista
sa imong ID kard sa plano sa panglawas, pindota ang 0. TTY 711
7. Bengali-Bangala অনুবাদকের অনুকরাধ থােকে, আপনার স্বাস্থ্য পররেল্পনার আই রি
োিড এ তারেোভূক্ত ও ের রদকত হকব না এমন টেরেক ান নরুমকর
ট ান ে্বন। (০) শূণ্য চাপুন। TTY 711
8. Burmese
CITY OF DENTON GOLD MEDICAL PLAN
2 ATTACHMENT IV – GETTING HELP IN OTHER LANGUAGES OR FORMATS
Language Translated Taglines
9. Cambodian-
Mon-Khmer
អ្នកមានសិទ្ធិទ្ទ្ួលជំនួយ និងព័ត៌មាន ជាភាសារបស់អ្នក ថោយមិនអ្ស់្ដលៃ។ ថ ើមបីថសនើស ំអ្នកបក្បរប សូមទ្ូរស័ពទថៅថលខឥតថេញ្ដលៃ
សំរាប់សមាជិក ្ប លមានកត់ថៅកនុងប័ណ្ណ ID គំថរាងស ខភាពរបស់អ្នក រួេថ ើយេ េ 0។ TTY 711
10. Cherokee Ꮎ ᎠᏎᏊ ᎨᎵ ᏗᏟᏃᎮᏗ ᏗᏎᏍᏗ ᏥᎪᏪᎳ ᎥᎿ ᏣᏤᎵ ᏙᎯ ᎨᏒ ᏗᎫᎪᏙᏗ
ᎪᏟᏍᏙᏗ ᏆᎾᏲᏍᏗᎢ, ᎭᏐᏅᏍᏓ 0. TTY 711
11. Chinese 您有權利免費以您的母語得到幫助和訊息。洽詢一位翻譯員，
請撥打您健保計劃會員卡上的免付費會員電話號碼，再按
0。聽力語言殘障服務專線 711
12. Choctaw Chim anumpa ya, apela micha nana aiimma yvt nan aivlli keyu ho ish
isha hinla kvt chim aiivlhpesa. Tosholi ya asilhha chi hokmvt chi
achukmaka holisso kallo iskitini ya tvli aianumpuli holhtena ya ibai
achvffa yvt peh pila ho ish i paya cha 0 ombetipa. TTY 711
13. Cushite-Oromo Kaffaltii male afaan keessaniin odeeffannoofi deeggarsa argachuuf
mirga ni qabdu. Turjumaana gaafachuufis sarara bilbilaa kan bilisaa
waraqaa eenyummaa karoora fayyaa keerratti tarreefame bilbiluun, 0
tuqi. TTY 711
14. Dutch U heeft het recht om hulp en informatie in uw taal te krijgen zonder
kosten. Om een tolk aan te vragen, bel ons gratis nummer die u op uw
ziekteverzekeringskaart treft, druk op 0. TTY 711
15. French Vous avez le droit d'obtenir gratuitement de l'aide et des
renseignements dans votre langue. Pour demander à parler à un
interprète, appelez le numéro de téléphone sans frais figurant sur
votre carte d’affilié du régime de soins de santé et appuyez sur la
touche 0. ATS 711.
16. French Creole-
Haitian Creole
Ou gen dwa pou jwenn èd ak enfòmasyon nan lang natifnatal ou
gratis. Pou mande yon entèprèt, rele nimewo gratis manm lan ki
endike sou kat ID plan sante ou, peze 0. TTY 711
17. German Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer
Sprache zu erhalten. Um einen Dolmetscher anzufordern, rufen Sie
die gebührenfreie Nummer auf Ihrer
Krankenversicherungskarte an und drücken Sie die 0. TTY 711
18. Greek Έχετε το δικαίωμα να λάβετε βοήθεια και πληροφορίες στη γλώσσα σας
χωρίς χρέωση. Για να ζητήσετε διερμηνέα, καλέστε το δωρεάν αριθμό
τηλεφώνου που βρίσκεται στην κάρτα μέλους ασφάλισης, πατήστε 0.
TTY 711
CITY OF DENTON GOLD MEDICAL PLAN
3 ATTACHMENT IV – GETTING HELP IN OTHER LANGUAGES OR FORMATS
Language Translated Taglines
19. Gujarati તમને વિના મૂલ્યે મદદ અને તમારી ભાષામાાં માહિતી મેળિિાનો
અવિકાર છે. દુભાવષયા માટે વિનાંતી કરિા, તમારા િેલ્થ પ્લાન ID
કાર્ડ રરની ૂૂીીમાાં પરેલ ટોલ-ફ્રી મેમ્બર ફોન નાંબર ઉરર કોલ
કરો, ૦ દબાિો. TTY 711
20. Hawaiian He pono ke kōkua ʻana aku iā ʻoe ma ka maopopo ʻana o kēia ʻike ma
loko o kāu ʻōlelo ponoʻī me ka uku ʻole ʻana.
E kamaʻilio ʻoe me kekahi kanaka unuhi, e kāhea i ka helu kelepona
kāki ʻole ma kou kāleka olakino, a e kaomi i ka helu 0. TTY 711.
21. Hindi आप के पास अपनी भाषा में सहायता एवं जानकारी नन:शुल्क फ्राप्त
करने का अधिकार है। दुभाषषए के लिए अनुरोि करने के लिए,
अपने हैल्थ प्िान ID कार्ड पर सूचीबद्ध टोि-प्री नंबर पर फ़ोन करें,
0 दबाएं। TTY 711
22. Hmong Koj muaj cai tau kev pab thiab tau cov ntaub ntawv sau ua koj hom
lus pub dawb. Yog xav tau ib tug neeg txhais, hu tus xov tooj rau tswv
cuab hu dawb uas sau muaj nyob ntawm koj daim yuaj them nqi kho
mob, nias 0. TTY 711.
23. Ibo Inwere ikike inweta enyemaka nakwa ịmụta asụsụ gị n’efu n’akwughị
ụgwọ. Maka ịkpọtụrụ onye nsụgharị okwu, kpọọ akara ekwentị nke dị
nákwụkwọ njirimara gị nke emere maka ahụike gị, pịa 0. TTY 711.
24. Ilocano Adda karbengam nga makaala ti tulong ken impormasyon iti
pagsasaom nga libre. Tapno agdawat iti maysa nga agipatarus,
tumawag iti toll-free nga numero ti telepono nga para kadagiti kameng
nga nakalista ayan ti ID card mo para ti plano ti salun-at, ipindut ti 0.
TTY 711
25. Indonesian Anda berhak untuk mendapatkan bantuan dan informasi dalam
bahasa Anda tanpa dikenakan biaya. Untuk meminta bantuan
penerjemah, hubungi nomor telepon anggota, bebas pulsa, yang
tercantum pada kartu ID rencana kesehatan Anda, tekan 0. TTY 711
26. Italian Hai il diritto di ottenere aiuto e informazioni nella tua lingua
gratuitamente. Per richiedere un interprete, chiama il numero
telefonico verde indicato sulla tua tessera identificativa del piano
sanitario e premi lo 0. Dispositivi per non udenti/TTY: 711
CITY OF DENTON GOLD MEDICAL PLAN
4 ATTACHMENT IV – GETTING HELP IN OTHER LANGUAGES OR FORMATS
Language Translated Taglines
27. Japanese ご希望の言語でサポートを受けたり、情報を入手したりする
ことができます。料金はかかりません。通訳をご希望の場合
は、医療プランのID
カードに記載されているメンバー用のフリーダイヤルまでお
電話の上、0を押してください。TTY専用番号は 711です。
28. Karen
29. Korean 귀하는 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수
있는 권리가 있습니다. 통역사를 요청하기 위해서는 귀하의
플랜 ID카드에 기재된 무료 회원 전화번호로 전화하여 0번을
누르십시오. TTY 711
30. Kru- Bassa Ni gwe kunde I bat mahola ni mawin u hop nan nipehmes be to
dolla. Yu kwel ni Kobol mahop seblana, soho ni sebel numba I ni
tehe mu I ticket I docta I nan, bep 0. TTY 711
31. Kurdish-Sorani تۆخ ینامز ەب تسیوێپ یرایناز و یتەمرای ،رەبمارەبێب ەک ەیەه تەوەئ یەفام
تیرگرەوینۆفەلەت ەرامژ ەب ەکب یدنەویەپ ،یکەراز یکێڕێگرەو یندرکاواد ۆب .
ناشاپ و تۆخ یتسوردنەت ینلاپ ییەسانیپ یتراک ید یائ وانەل وارسوون 0 ەرگاد
.TTY 711
32. Laotian ທ່ານມີສິດທີ່ຈະໄດ້ຮັບການຊ່ວຍເຫ ຼືອແລະຂ ້ມູນຂ່າວສານທີ່ເປັນພາສ
າຂອງທ່ານບ ່ມີຄ່າໃຊ້ຈ່າຍ.
ເພຼື່ອຂ ຮ້ອງນາຍພາສາ,ໂທຟຣີຫາຫມາຍເລກໂທລະສັບສ າລັບສະມາ
ຊິກທີ່ໄດ້ລະບຸໄວ້ໃນບັດສະມາຊິກຂອງທ່ານ,ກົດເລກ 0. TTY 711
33. Marathi आपल्यािा आपल्या भाषेत षवनामूल्य मदत आणि माहहती
लमळण्याचा अधिकार आहे. दूभाषकास षवनंती करण्यासाठी आपल्या
आरोग्य योजना ओळखपत्रावरीि सूचीबध्द केिेल्या सदस्यास
षवनामूल्य ोोन नंबरवर संपकड करण्यासाठी दाबा 0. TTY 711
34. Marshallese Eor aṃ maroñ ñan bok jipañ im meḷeḷe ilo kajin eo aṃ ilo
ejjeḷọk wōṇāān. Ñan kajjitōk ñan juon ri-ukok, kūrḷok nōṃba
eo eṃōj an jeje ilo kaat in ID in karōk in ājmour eo aṃ, jiped
0. TTY 711
35. Micronesian-
Pohnpeian
Komw ahneki manaman unsek komwi en alehdi sawas oh
mengihtik ni pein omwi tungoal lokaia ni soh isepe. Pwen peki
sawas en soun kawehweh, eker delepwohn nempe ong towehkan
me soh isepe me ntingihdi ni pein omwi doaropwe me pid
koasoandi en kehl, padik 0. TTY 711.
CITY OF DENTON GOLD MEDICAL PLAN
5 ATTACHMENT IV – GETTING HELP IN OTHER LANGUAGES OR FORMATS
Language Translated Taglines
36. Navajo T'áá jíík'eh doo bą́ą́h 'alínígóó bee baa hane'ígíí t'áá ni nizaád bee
niká'e'eyeego bee ná'ahoot'i'. 'Ata' halne'í ła yíníkeedgo, ninaaltsoos
nit‘iz7 ‘ats’77s bee baa’ahay1 bee n44hozin7g77 bik11’ b44sh bee
hane’7 t’11 j77k’eh bee hane’7 bik1’7g77 bich’8’ hodíilnih dóó 0
bił 'adidíílchił. TTY 711
37. Nepali तपाई ंले आफ् नो षामा ा ःनुल्क स योगोर ज नानसाजप रापात ग रनअ िःासाज तपाई ंय र
छ। िन्वादस रापात ग रजपपाऊ षनप िन्जोा रनन, तपाई ंसो स्वास््ग गोनना परजचग सार्न ा
यूचपसृत टोल-फ्री यदस्ग फोन नम् बज ा यम्पसन रन्नोोय्, 0 ःिच् न्ोोय्। TTY 711
38. Nilotic-Dinka Yin nɔŋ löŋ bë yi kuɔny në wɛ̈rëyic de thöŋ du äbac ke cin wëu tääue
ke piny. Äcän bä ran yë kɔc ger thok thiëëc, ke yin cɔl nämba yene yup
abac de ran töŋ ye kɔc wäär thok tɔ në ID kat duön de pänakim yic,
thäny 0 yic. TTY 711.
39. Norwegian Du har rett til å få gratis hjelp og informasjon på ditt eget språk.
For å be om en tolk, ring gratisnummeret for medlemmer som er
oppført på helsekortet ditt og trykk 0. TTY 711
40. Pennsylvania
Dutch
Du hoscht die Recht fer Hilf unn Information in deine Schprooch
griege, fer nix. Wann du en Iwwersetzer hawwe willscht, kannscht du
die frei Telefon Nummer uff dei Gesundheit Blann ID Kaarde yuuse,
dricke 0. TTY 711
41. Persian-Farsi .دییامن تفایرد ناگیار روط ەب ار دوخ نابز ەب تاعلاطا و کمک ەک دیراد قح امش
هرامش اب یهافش مجرتم تساوخرد یارب نفلت ناگیار دیق هدش رد تراک ییاسانش
ەمانرب یتشادهب دوخ و هدومن لصاح سامت0 .دیهد راشف ارTTY 711
42. Punjabi ਤੁਹਾਡੇ ਕੋਲ ਆਪਣੀ ਭਾਸ਼ਾ ਵ ਿੱਚ ਸਹਾਇਤਾ ਅਤੇ ਜਾਣਕਾਰੀ ਮੁਫ਼ਤ ਪਰਾਪਤ ਕਰਨ
ਦਾ ਅਵਿਕਾਰ ਹੈ| ਦੁਭਾਸ਼ੀਏ ਲਈ ਤੁਹਾਡੇ ਹੈਲਥ ਪਲਾਨ ਆਈਡੀ ਵਦਿੱਤੇ ਗਏ ਟਾਿੱਲ
ਫ਼ਰੀ ਮੈਂਬਰ ਫ਼ੋਨ ਨੰ ਬਰ ਟੀਟੀ ਾਈ 711 ਤੇ ਕਾਿੱਲ ਕਰੋ, 0 ਦਿੱਬੋ|
43. Polish Masz prawo do uzyskania bezpłatnej informacji i pomocy we
własnym języku. Po usługi tłumacza zadzwoń pod bezpłatny numer
umieszczony na karcie identyfikacyjnej planu medycznego i wciśnij 0.
TTY 711
44. Portuguese Você tem o direito de obter ajuda e informação em seu idioma e
sem custos. Para solicitar um intérprete, ligue para o número de
telefone gratuito que consta no cartão de ID do seu plano de
saúde, pressione 0. TTY 711
45. Romanian Aveți dreptul de a obține gratuit ajutor și informații în limba
dumneavoastră. Pentru a cere un interpret, sunați la numărul de
telefon gratuit care se găsește pe cardul dumneavoastră de sănătate,
apăsați pe tasta 0. TTY 711
CITY OF DENTON GOLD MEDICAL PLAN
6 ATTACHMENT IV – GETTING HELP IN OTHER LANGUAGES OR FORMATS
Language Translated Taglines
46. Russian Вы имеете право на бесплатное получение помощи и
информации на вашем языке. Чтобы подать запрос переводчика
позвоните по бесплатному номеру телефона, указанному на
обратной стороне вашей идентификационной карты и нажмите
0. Линия TTY 711
47. Samoan-
Fa’asamoa E iai lou āiā tatau e maua atu ai se fesoasoani ma
fa’amatalaga i lau gagana e aunoa ma se totogi. Ina ia
fa’atalosagaina se tagata fa’aliliu, vili i le telefoni mo sui e le
totogia o loo lisi atu i lau peleni i lau pepa ID mo le soifua
maloloina, oomi le 0. TTY 711.
48. Serbo-Croation Imate pravo da besplatno dobijete pomoć i informacije na Vašem
jeziku. Da biste zatražili prevodioca, nazovite besplatni broj
naveden na iskaznici Vašeg zdravstenog osiguranja i pritisnite 0.
TTY 711.
49. Spanish Tiene derecho a recibir ayuda e información en su idioma sin costo.
Para solicitar un intérprete, llame al número de teléfono gratuito para
miembros que se encuentra en su tarjeta de identificación del plan de
salud y presione 0.
TTY 711
50. Sudanic-
Fulfulde
Ɗum hakke maaɗa mballeɗaa kadin keɓaa habaru nder wolde maaɗa
naa maa a yoɓii. To a yiɗi pirtoowo, noddu limngal mo telefol caahu
limtaaɗo nder kaatiwol ID maaɗa ngol njamu, nyo’’u 0. TTY 711.
51. Swahili Una haki ya kupata msaada na taarifa kwa lugha yako bila
gharama. Kuomba mkalimani, piga nambariya wanachama ya bure
iliyoorodheshwa kwenye TAM ya kadi yako ya mpango wa afya,
bonyeza 0. TTY 711
52. Syriac-Assyrian ܢܲܘ݂ܟܘܵܢܵܫܸܠܒ ܐ ܵܬܼܘܢܵܥܕܘ ܼܲܡܘ ܐ ܵܬܪܼܲܝܼܲܗ ܢܲܘܬܼܝܠܒ ܼܲܩܕ ܐ ܵܬܼܘܩܼܲܚ ܢܲܘ݂ܟܘܵܠܬܼܝܐ ܢܲܘܬܚ ܼܲܐ
ܲܘܟܚ ܼܲܡܠ ܬܼܝܐܵܢܵܓܼܲܡ ܗܹܠܼܝܐܕ ܢܲܘܦܼܝܠܹܬ ܐܵܢܵܝܢܸܡ ܠ ܼܲܥ ܢܲܘܪܩ ،ܐܵܢܵܡܓܪ ܼܲܬܡ ܕ ܼܲܚ ܡ ܼܲܥ ܐܹܝ
ܼܝܚܡܘ ܐܵܢܵܡܠܼܘܚܕ ܐܵܩܬܸܦ ܕܸܠܸܐ ܐܼܵܒܼܝܼܬܟ0 .TTY 711
53. Tagalog May karapatan kang makatanggap ng tulong at impormasyon sa iyong
wika nang walang bayad. Upang humiling ng tagasalin, tawagan ang
toll-free na numero ng telepono na nakalagay sa iyong ID card ng
planong pangkalusugan, pindutin ang 0. TTY 711
54. Telugu ఎల ాంటి ఖర్చు లేక ాండా మీ భాషలో సాయాంబు మరియు సమ చార్ ప ాంద
డానికి మీక హక ు ఉాంది. ఒకవేళ దుబాషి కావాలాంటే, మీ హెల్త్ పాా న్ ఐడి
కార్చు మీద జాబితా చేయబడ్ు టోల్త ్నరీ ఫ ాంబర్చక ఫో న్ చేసి, 0 ్పరీస్ చేసో ు.
TTY 711
CITY OF DENTON GOLD MEDICAL PLAN
7 ATTACHMENT IV – GETTING HELP IN OTHER LANGUAGES OR FORMATS
Language Translated Taglines
55. Thai คุณมีสิทธิที่จะได้รับความช่วยเหลือและข้อมูลในภาษาของคุณได้โดยไม่มีค่าใช้จ่าย
หากต้องการขอล่ามแปลภาษา
โปรดโทรศัพท์ถึงหมายเลขโทรฟรีที่อยู่บนบัตรประจ าตัวส าหรับแผนสุขภาพของคุณ แล้วกด 0
ส าหรับผู้ที่มีความบกพร่องทางการได้ยินหรือการพูด โปรดโทรฯถึงหมายเลข 711
56. Tongan-
Fakatonga
‘Oku ke ma’u ‘a e totonu ke ma’u ’a e tokoni mo e ‘u fakamatala ‘i
ho’o lea fakafonua ta’etotongi. Ke kole ha tokotaha fakatonulea, ta ki
he fika telefoni ta’etotongi ma’ae kau memipa ‘a ee ‘oku lisi ‘I ho’o
kaati ID ki ho’o palani ki he mo’uilelei, Lomi’I ‘a e 0. TTY 711
57. Trukese
(Chuukese)
Mi wor omw pwung om kopwe nounou ika amasou noum ekkewe
aninis ika toropwen aninis nge epwe awewetiw non kapasen
fonuom, ese kamo. Ika ka mwochen tungoren aninisin chiakku,
kori ewe member nampa, ese pwan kamo, mi pachanong won an
noum health plan katen ID, iwe tiki "0". Ren TTY, kori 711.
58. Turkish Kendi dilinizde ücretsiz olarak yardım ve bilgi alma hakkınız
bulunmaktadır. Bir tercüman istemek için sağlık planı kimlik kartınızın
üzerinde yer alan ücretsiz telefon numarasını arayınız, sonra 0’a
basınız. TTY (yazılı iletişim) için 711
59. Ukrainian У Вас є право отримати безкоштовну допомогу та інформацію на
Вашій рідній мові. Щоб подати запит про надання послуг
перекладача, зателефонуйте на безкоштовний номер телефону
учасника, вказаний на вашій ідентифікаційній карті плану
медичного страхування, натисніть 0. TTY 711
60. Urdu نامجرت یسک ۔ےہ قح اک ےنرک لصاح تامولعم روا ددم تفم ںيم نابز ینپا وک پآ
هتليہ ےک پآ وج ںيرک لاک رپ ربمن نوف ربمم یرف لوٹ ،ےئل ےک ےنرک تاب ےس
،ےہ جرد رپ ڈراک یڈ یئآ نلاپ0 ۔ںيئابد TTY 711
61. Vietnamese Quý vị có quyên được giúp đỡ và cấp thông tin bằng ngôn ngữ của
quý vị miền phí. Đ́ yêu cầu được thông dịch viên giúp đỡ, vui lòng
gọi số điểễn thoải miền phí dành cho hội viên được nêu trên thẻ ID
chương tr̀inh bạo hím y tệ của quý vị, bấm số 0. TTY 711
62. Yiddish ער יד טאה ריא ןופ יירפ ךארפש רעייא ןיא עיצאמראפניא ןוא ףליה ןעמוקאב וצ טכ
טפור ,רעשטעמלאד א ןעגנאלראפ וצ .לאצפא
ןאלפ טלעה רעייא ףיוא טייטש סאוו רעמונ ןאפעלעט רעבמעמ עיירפ לאט םעדID
לטראק , טקורד0 .TTY 711
63. Yoruba O ní ẹtọ lati rí iranwọ àti ìfitónilétí gbà ní èdè rẹ láìsanwó. Láti bá
ògbufọ kan sọrọ, pè sórí nọmbà ẹrọ ibánisọrọ láisanwó ibodè ti a tò
sóri kádi idánimọ ti ètò ilera rẹ, tẹ ‘0’. TTY 711
CITY OF DENTON GOLD MEDICAL PLAN
8 ADDENDUM - UNITEDHEALTH ALLIES
ADDENDUM - UNITEDHEALTH ALLIES
Introduction
This Addendum to the Summary Plan Description provides discounts for select non-
Covered Health Services from Physicians and health care professionals.
When the words "you" and "your" are used the Plan is referring to people who are Covered
Persons as the term is defined in the Summary Plan Description (SPD). See Section 14,
Glossary in the SPD.
Important:
UnitedHealth Allies is not a health insurance plan. You are responsible for the full cost of
any services purchased, minus the applicable discount. Always use your health insurance
plan for Covered Health Services described in the Summary Plan Description (see Section
5, Plan Highlights) when a benefit is available.
What is UnitedHealth Allies?
UnitedHealth Allies is a health value program that offers savings on certain products and
services that are not Covered Health Services under your health plan.
Because this is not a health insurance plan, you are not required to receive a referral or
submit any claim forms.
Discounts through UnitedHealth Allies are available to you and your Dependents as defined
in the Summary Plan Description in Section 14, Glossary.
Selecting a Discounted Product or Service
A list of available discounted products or services can be viewed online at
www.Unitedhealthallies.com or by calling the number on the back of your ID card.
After selecting a health care professional and product or service, reserve the preferred rate
and print the rate confirmation letter. If you have reserved a product or service with a
customer service representative, the rate confirmation letter will be faxed or mailed to you.
Important:
You must present the rate confirmation at the time of receiving the product or service in
order to receive the discount.
Visiting Your Selected Health Care Professional
After reserving a preferred rate, make an appointment directly with the health care
professional. Your appointment must be within ninety (90) days of the date on your rate
confirmation letter.
CITY OF DENTON GOLD MEDICAL PLAN
9 ADDENDUM - UNITEDHEALTH ALLIES
Present the rate confirmation and your ID card at the time you receive the service. You will
be required to pay the preferred rate directly to the health care professional at the time the
service is received.
Additional UnitedHealth Allies Information
Additional information on the UnitedHealth Allies program can be obtained online at
www.Unitedhealthallies.com or by calling the number on the back of your ID card.
CITY OF DENTON GOLD MEDICAL PLAN
10 ADDENDUM - PARENTSTEPS®
ADDENDUM - PARENTSTEPS®
Introduction
This Addendum to the Summary Plan Description illustrates the benefits you may be eligible
for under the ParentSteps® program.
When the words "you" and "your" are used the Plan is referring to people who are Covered
Persons as the term is defined in the Summary Plan Description (SPD). See Section 14,
Glossary in the SPD.
Important:
ParentSteps® is not a health insurance plan. You are responsible for the full cost of any
services purchased. ParentSteps® will collect the provider payment from you online via
the ParentSteps® website and forward the payment to the provider on your behalf.
Always use your health insurance plan for Covered Health Services described in the
Summary Plan Description Section 5, Plan Highlights, when a benefit is available.
What is ParentSteps®?
ParentSteps® is a discount program that offers savings on certain medications and services
for the treatment of infertility that are not Covered Health Services under your health plan.
This program also offers:
■ Guidance to help you make informed decisions on where to receive care.
■ Education and support resources through experienced infertility nurses.
■ Access to providers contracted with UnitedHealthcare that offer discounts for infertility
medical services.
■ Discounts on select medications when filled through a designated pharmacy partner.
Because this is not a health insurance plan, you are not required to receive a referral or
submit any claim forms.
Discounts through this program are available to you and your Dependents. Dependents are
defined in the Summary Plan Description in Section 14, Glossary.
Registering for ParentSteps®
Prior to obtaining discounts on infertility medical treatment or speaking with an infertility
nurse you need to register for the program online at
www.myoptumhealthparentsteps.com or by calling ParentSteps® toll-free at 1-877-801-
3507.
CITY OF DENTON GOLD MEDICAL PLAN
11 ADDENDUM - PARENTSTEPS®
Selecting a Contracted Provider
After registering for the program you can view ParentSteps® facilities and clinics online
based on location, compare IVF cycle outcome data for each participating provider and see
the specific rates negotiated by ParentSteps® with each provider for select types of infertility
treatment in order to make an informed decision.
Visiting Your Selected Health Care Professional
Once you have selected a provider, you will be asked to choose that clinic for a consultation.
You should then call and make an appointment with that clinic and mention you are a
ParentSteps® member. ParentSteps® will validate your choice and send a validation email to
you and the clinic.
Obtaining a Discount
If you and your provider choose a treatment in which ParentSteps® discounts apply, the
provider will enter in your proposed course of treatment. ParentSteps® will alert you, via
email, that treatment has been assigned. Once you log in to the ParentSteps® website, you
will see your treatment plan with a cost breakdown for your review.
After reviewing the treatment plan and determining it is correct you can pay for the
treatment online. Once this payment has been made successfully ParentSteps® will notify
your provider with a statement saying that treatments may begin.
Speaking with a Nurse
Once you have successfully registered for the ParentSteps® program you may receive
additional educational and support resources through an experienced infertility nurse. You
may even work with a single nurse throughout your treatment if you choose.
For questions about diagnosis, treatment options, your plan of care or general support,
please contact a ParentSteps® nurse via phone (toll-free) by calling 1-866-774-4626.
ParentSteps® nurses are available from 8 a.m. to 5 p.m. Central Time; Monday through
Friday, excluding holidays.
Additional ParentSteps® Information
Additional information on the ParentSteps® program can be obtained online at
www.myoptumhealthparentsteps.com or by calling 1-877-801-3507 (toll-free).
CITY OF DENTON GOLD MEDICAL PLAN
12 ADDENDUM - PARENTSTEPS®
50174416 008 - 3/31/2017