Health Care Plan - Boeing · Health Care Plan Supplement to the Health Care Plans Booklet 2005 United Healthcare ... seven days a week, on line and by telephone

United Healthcare Coordinated Care Plan | 2005 Edition A12557W

Health Care PlanSupplement to the Health Care Plans Booklet

2005 United Healthcare Coordinated Care Plan Supplement (Nonunion Employees)

The summary plan description (SPD) for this Plan is this booklet, the nonunion Health Care Plans booklet, and any summaries of material modifications (Updates). Updates are issued if the Company adds to or changes benefits in the Plan after the SPD is published. The Updates, if any, are incorporated at the end of this booklet.

The content and delivery of this booklet are intended to comply with the Employee Retirement Income Security Act of 1974, as amended (ERISA). If there is any conflict between the information in this booklet and the official Plan document, the official Plan document will govern.

UnitedHealthcare Coordinated Care Plan Nonunion Employees | 2005 Edition A12557 – 1

Plan Information and NoticeThis description of the UnitedHealthcare coordinated care plan and accompanying mental health and substance abuse, prescription drug, and vision care programs is a supplement to the current Health Care Plans booklet, and updates, for nonunion employees of The Boeing Company (the “Company”).

Under the UnitedHealthcare coordinated care plan, you may choose any legally qualifi ed physician or hospital each time you need health care services. However, when you use network providers, you receive the highest benefi ts under the plan. The plan is available to you if you live in the network service area (St. Louis and the surrounding counties), as described on page 13.

See your Health Care Plans booklet, and updates, for

• Eligibility and enrollment provisions, including contribution information.

• Termination of coverage provisions.

• Special disclosure and other general plan information.

Summary Plan Description and Plan DocumentThis supplement, any summaries of material modifi cations, the applicable provider directory, and the current Health Care Plans booklet, and updates, for nonunion employees are the summary plan description for the UnitedHealthcare coordinated care plan and accompanying mental health and substance abuse, prescription drug, and vision care programs.

The contents and delivery of these booklets are intended to comply with the Employee Retirement Income Security Act of 1974, as amended. If there is any confl ict between the information in this booklet and the offi cial Plan document, the offi cial Plan document will govern.

Any representations contrary to the Plan are not binding.

UpdatesPeriodically, the Company may add to or change benefi ts. If this happens, you will receive an Update describing the changes. Be sure to keep any Updates with this booklet.

Notice of Company RightsThe Company fully intends to continue the Plan. However, the Company reserves the right to terminate, suspend, or modify any benefi ts described in this booklet, in whole or in part, at any time, and for any reason for employees, former employees, retirees, and their dependents. The Plan Administrator, Boeing Service Center for Health and Insurance Plans (“Boeing Service Center”), and service representatives have the right to recover overpayments, regardless of the cause, nature, or source of the overpayments.

This summary plan description booklet does not guarantee current or future employment or benefi ts. Receiving benefi ts under this Plan does not restrict the Company’s rights to discharge any employee at any time.

For important terms used in this booklet, see “Defi nitions,” beginning on page 48.

This booklet highlights the benefi ts available to eligible employees and their eligible dependents under the UnitedHealthcare coordinated care plan as of January 1, 2005.

2 – A12557 UnitedHealthcare Coordinated Care Plan Nonunion Employees | 2005 Edition

Medical Plan HighlightsThe Company offers comprehensive medical coverage that is designed to help you stay healthy and manage costs in the event of serious illness or injury. This Company-sponsored health care plan includes

• Coverage for major medical services.

• Preventive medical care programs.

• A network of quality physicians and hospitals.

• Tools and resources to fi nd the care you need, when you need it.

• Mental health and substance abuse coverage.

• Prescription drug benefi ts.

• Vision care.

This booklet provides the information you need to help you access plan tools and resources, understand and use your benefi ts, and manage your health care costs.

What This Supplemental Booklet IncludesThis supplement provides information about

• How the UnitedHealthcare coordinated care plan works, including covered services and supplies as well as how much you and the Company pay.

• How to fi le claims for services and appeals if you are denied coverage or services.

What This Supplemental Booklet Does Not IncludeSee your Health Care Plans booklet for details on eligibility and enrollment, contributions, termination of coverage, and special disclosure and other general plan information.

Network Provider DirectoryThis health care plan uses a network of providers. You can obtain a network provider directory or a list of network providers at no cost to you by

• Connecting to the Your Benefi ts Resources web site and searching the online provider directory.

• Calling the service representative directly or through Boeing TotalAccess.

• Visiting the web site for your service representative.

For telephone numbers and web site addresses, see “Where to Get Information,” beginning on page 53.

Providers move in and out of networks periodically. Before you receive services, be sure to confi rm with your provider or the service representative that your provider still is participating in the plan’s network.


When You Need More InformationThroughout this booklet, you will be referred to these main sources for additional information:

• Boeing TotalAccess.

• The Boeing Service Center and its web site, Your Benefi ts Resources.

• Service representatives.

Boeing TotalAccess is your gateway to benefi ts information. Boeing TotalAccess connects you directly with many service representatives and other resources.

You can contact Boeing TotalAccess 24 hours a day, seven days a week, on line and by telephone.

• On the Boeing Web (at work): Log on to https://my.boeing.com and click the TotalAccess tab.

• On the World Wide Web: Log on to https://my-ext.boeing.com using your BEMS ID number (or Social Security number) and your Boeing TotalAccess password.

• By telephone: Call 1-866-473-2016. Hearing-impaired callers can access TTY/TDD services by calling 1-800-755-6363. Choose health and insurance from the menu and follow the prompts.

The Boeing TotalAccess telephone system will direct you to the resources you need. You must have your BEMS ID number (or Social Security number) and Boeing TotalAccess password when you call. Boeing TotalAccess representatives are available to assist you and answer questions Monday through Friday from 7 a.m. to 8 p.m. Central time.

The Boeing Service Center and its web site, Your Benefi ts Resources, provide information about your medical plan options and costs. You can connect to

• The Your Benefi ts Resources web site on line through Boeing TotalAccess on the Boeing Web and World Wide Web. (See above.)

• The Boeing Service Center by calling Boeing TotalAccess. (See above.)

Service Representatives. The Company has engaged third-party organizations, called service representatives, to administer the plans, make benefi t determinations, and pay claims. Each service representative answers benefi t and claim questions by telephone, and many provide web sites. Connect to a service representative by

• Calling Boeing TotalAccess. (See above.)

• Connecting to the service representative’s web site directly. (See page 53.)

• Calling the telephone number on the back of your health care identifi cation card.

When you see a reference to contact any of these resources, you will see an icon. Each time you see this icon, refer to “Where to Get Information,” beginning on page 53, for telephone numbers, addresses, and web sites.


Table of ContentsHow the Medical Plan Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

How You and the Medical Plan Share Costs . . . . . . . . . . . . . . . . . . . 8

What You Pay. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

What the Plan Pays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Network Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

How Medical Expenses Are Paid. . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Network Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Nonnetwork Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Coverage for a Child Who Does Not Live With You . . . . . . . . . 13

Coverage When You Are Traveling . . . . . . . . . . . . . . . . . . . . . . 13

Network Benefi t Payment Levels and Maximums . . . . . . . . . . . . . 14

Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Offi ce Visit Copayment . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Emergency Room Copayment . . . . . . . . . . . . . . . . . . . . . . 14

Lifetime Maximum Benefi t . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Nonnetwork Benefi t Payment Levels and Maximums . . . . . . . . . . 15

Annual Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Out-of-Pocket Expense Limit . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Lifetime Maximum Benefi t . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Other Medical Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Reasonable and Customary Allowances . . . . . . . . . . . . . . . . . . 16

Advance Estimate of Reasonable and Customary Allowance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Medical Review Program for Nonnetwork Hospitalization . . . 17

Preadmission Certifi cation. . . . . . . . . . . . . . . . . . . . . . . . . 17

Continued Stay Review . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Medical Case Management . . . . . . . . . . . . . . . . . . . . . . . . 18

What the Medical Plan Covers—Network Services and Supplies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Emergency and Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Hospital Alternatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Hospital Services and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . 19

Hospital Stay Rules for Mothers and Newborns . . . . . . . . 19

Medical Services and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . 20

Physician Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Preventive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

How to Submit a Network Medical Claim . . . . . . . . . . . . . . . . 24

What the Medical Plan Covers—Nonnetwork Services and Supplies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24


Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Christian Science Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Skilled Nursing Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

How to Submit a Nonnetwork Medical Claim . . . . . . . . . . . . . 24

What the Medical Plan Does Not Cover—Network or Nonnetwork Services and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . 25

What the Medical Plan Does Not Cover—NonnetworkServices and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Mental Health and Substance Abuse Program . . . . . . . . . . . . . . . . . . . . . . . 28

Assessment and Referral Process . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Payment Provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

With Assessment and Referral . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Without Assessment and Referral . . . . . . . . . . . . . . . . . . . . . . . 28

Mental Health Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Substance Abuse Treatment . . . . . . . . . . . . . . . . . . . . . . . . 29

Lifetime Maximum Benefi t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Mental Health Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Substance Abuse Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

What the Plan Covers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Mental Health Treatment (Including Eating Disorders) . . . . . . 30

Substance Abuse Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

How to Submit a Mental Health or Substance Abuse Claim. . . . . . 30

Prescription Drug Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Formulary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Maximum Quantity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

How to Fill a Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Participating Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Nonparticipating Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Mail Service Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Covered Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

What the Prescription Drug Program Does Not Cover . . . . . . . . . . 33

Vision Care Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

How to Obtain Vision Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Making an Appointment With a VSP Doctor. . . . . . . . . . . . . . . 35

Covered Services and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Benefi t Payment Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Benefi t Limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

What the Vision Care Program Does Not Cover . . . . . . . . . . . . . . . 36

How to Submit a Vision Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Review and Appeal Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Medical Benefi t Claims Process . . . . . . . . . . . . . . . . . . . . . . . . . . . 38


How to File a Claim for Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . 38

Time Limits for Decisions on Benefi t Claims . . . . . . . . . . 39

If Your Benefi t Claim Is Denied. . . . . . . . . . . . . . . . . . . . . . . . . 40

How to Appeal if Your Benefi t Claim Is Denied . . . . . . . . 40

Time Limits for Decisions on Benefi t Appeals . . . . . . . . . 41

If Your Benefi t Appeal Is Denied . . . . . . . . . . . . . . . . . . . . . . . . 42

Whom to Contact for Benefi t Claim and Appeal Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Eligibility Claims Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

How to File a Claim for Eligibility . . . . . . . . . . . . . . . . . . . . . . 42

Time Limits for Decisions on Eligibility Claims. . . . . . . . 43

If Your Eligibility Claim Is Denied . . . . . . . . . . . . . . . . . . . . . . 43

How to Appeal if Your Eligibility Claim Is Denied . . . . . . 44

Time Limits for Decisions on Eligibility Appeals . . . . . . . 44

If Your Eligibility Appeal Is Denied . . . . . . . . . . . . . . . . . . . . . 45

Whom to Contact for Eligibility Claim and Appeal Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

What You Can Do if Your Appeal Is Denied . . . . . . . . . . . . . . . 45

How Claims Are Paid When You Have Duplicate Coverage. . . . . . 45

Determine Whether the Plan Is Primary or Secondary . . . . . . . 46

If You Are Covered by Two Boeing-Sponsored Plans . . . . 46

If You Are Covered by Medicare and This Plan . . . . . . . . 47

Claim Administration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

When an Illness or Injury Is Caused by the Negligence of Another . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Conversion of Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Defi nitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Where to Get Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53


How the Medical Plan WorksThe UnitedHealthcare coordinated care plan is offered to employees and their dependents who live or work in the network service area (St. Louis and the surrounding counties).

The plan provides you and your eligible dependents with fi nancial protection against large and often unforeseen medical expenses. It also covers many other medical services and supplies such as preventive care and physician and hospital services.

Although you may obtain care from any legally qualifi ed physician, you receive the highest benefi ts under the plan when you obtain covered medical services and supplies from a network provider.

You do not need to obtain a referral before receiving services from network medical specialists. However, referrals are required for mental health and substance abuse treatment.

The following sections summarize the plan benefi ts and out-of-pocket expenses. You are especially encouraged to read the medical review program requirements (beginning on page 17) because the regular benefi t payment levels under the plan may be limited or denied if the program requirements are not followed.

Benefi t and plan payment provisions are based on a calendar year, which is January 1 through December 31.

The plan is administered by UnitedHealthcare (the service representative). The Company may change the service representative at any time.


What You Pay

This chart shows what you will be responsible for paying for your medical coverage. The chart that begins on the next page, “What the Plan Pays,” shows how much the plan pays.

What You Pay* Network Provider Nonnetwork ProviderAnnual deductible (based on the January 1–December 31 calendar year)

None $500 per person

Annual out-of-pocket expense limit (based on the January 1–December 31 calendar year)

None $3,000 per person (in addition to the annual deductible)

Copayments (annual deductible does not apply)

• $10 copayment for each offi ce visit

• $10 copayment for each specialist visit

• For pregnancy visits, copayment applies to fi rst visit only

• $50 copayment for each emergency room visit (waived if the patient is admitted or dies)

None

Coinsurance percentage Generally, you pay nothing and the plan pays 100% (after you pay copayments)

Generally, after you reach the deductible, the plan pays 60% of the next $7,500 of covered expenses in a calendar year ($4,500) and you pay 40% of the next $7,500 of covered expenses in a calendar year ($3,000)

Lifetime maximum benefi t None $1.5 million per person* Payment provisions differ for the mental health and substance abuse, prescription drug, and vision care programs, as described later in this booklet.

How You and the Medical Plan Share Costs


What the Plan Pays

The plan pays benefi ts for medically necessary services and supplies at the following percentages after you pay any copayment, annual deductible, or combination of the two. Claims are administered by UnitedHealthcare, except as noted in this chart. For details, see “What the Medical Plan Covers—Network Services and Supplies,” beginning on page 18, and “What the Medical Plan Covers—Nonnetwork Services and Supplies,” on page 24.

Covered Services and Supplies Network Provider* Nonnetwork Provider**Acupuncture Not covered 60%; deductible applies

Ambulance 100% • 100% emergency

• 60% nonemergency; deductible applies

Anesthetist 100% after $10 copayment outpatient

60%; deductible applies

Christian Science treatment Not covered 60%; deductible applies

Cosmetic surgery 100% for limited conditions 60% for limited conditions; deductible applies

Diagnostic X-ray and laboratory services

100% 60%; deductible applies

Durable medical equipment 100% 60%; deductible applies

Emergency room treatment

• Medical emergency (must meet the defi nition of emergency)

• $50 copayment

• The $50 copayment is waived if you are admitted as inpatient immediately after emergency room care or die in the emergency room

Same as network provisions

• All other treatment 60% after $50 copayment for nonemergency care

Same as network provisions

Erectile dysfunction 100% 60%; deductible applies

Freestanding surgical facilities 100% 60%; deductible applies

Hearing (network and nonnetwork combined)

• Examinations • 100% after $10 copayment per examination

• Limited to one audiologist examination every three benefi t years

• 60%; deductible applies

• Limited to one audiologist examination every three benefi t years

• Hearing aids • 100%

• Limited to one standard aid per ear every three benefi t years

Not covered (except emergency)

Home health care 100% • 60%; deductible applies

• Limited to 40 visits per year

Hospice care 100% 60%; deductible applies

Hospital 100% 60%; deductible applies

Infertility diagnosis and treatment 100% 60%; deductible applies

Continued on page 10


What the Plan Pays (continued)


Covered Services and Supplies Network Provider* Nonnetwork Provider**Mental health treatment (including eating disorders)

• See “Mental Health and Substance Abuse Program,” later in this booklet

• Care is managed by ValueOptions

• Covered inpatient, partial hospital, or intensive outpatient services

100% when obtained from a provider certifi ed by ValueOptions

• Separate mental health and substance abuse annual deductible of $500 per person

• 60% when obtained from a provider not certifi ed by ValueOptions

• Limited to 20 days per year

• Covered outpatient services 100% after $10 copayment when obtained from a provider certifi ed by ValueOptions




Orthopedic appliances and braces; orthotics


Oxygen 100% 60%; deductible applies

Physician

• Inpatient 100% 60%; deductible applies

• Offi ce visit (including home, hospital outpatient, and second surgical opinion)

100% after $10 copayment 60%; deductible applies

Pregnancy 100% after $10 copayment initial visit only

60%; deductible applies

Prescription drugs Pharmacy benefi ts are managed by Medco Health Solutions

• Retail participating pharmacy (30-day supply)

Not covered

• Generic $5 copayment

• Formulary brand-name $15 copayment

• Nonformulary brand-name $30 copayment

• Mail service program (90-day supply)

Not covered

• Generic $10 copayment

• Formulary brand-name $30 copayment

• Nonformulary brand-name $60 copayment


What the Plan Pays (continued)


Covered Services and Supplies Network Provider* Nonnetwork Provider**Preventive care

• Routine physical examinations—employees and spouses

100% Not covered

• Routine physical examinations—children (age 2 and older)


• Well-baby care—children (to age 24 months)

100% Not covered

• Routine mammograms and prostate screenings


• Routine Pap tests 100% Not covered

• Routine immunizations for children

100% after $10 copayment 60%; deductible applies

Skilled nursing facility care (for limited conditions)


Spinal and extremity manipulations (such as chiropractic care); 26 visits per year (network and nonnetwork combined)

$10 copayment 60%; deductible applies

Second opinions before surgery 100% after $10 copayment 60%; deductible applies

Substance abuse treatment • See “Mental Health and Substance Abuse Program,” later in this booklet

• Care is managed by ValueOptions

• Covered inpatient, partial hospital, or intensive outpatient services

100% when obtained from a provider certifi ed by ValueOptions


• 60% when obtained from a provider not certifi ed by ValueOptions to a maximum of $200 per day

• Limited to 20 days per year

• Covered outpatient services 100% after $10 copayment when obtained from a provider certifi ed by ValueOptions





What the Plan Pays (continued)The plan pays benefi ts for medically necessary services and supplies at the following percentages after you pay any copayment, annual deductible, or combination of the two. Claims are administered by UnitedHealthcare, except as noted in this chart. For details, see “What the Medical Plan Covers—Network Services and Supplies,” beginning on page 18, and “What the Medical Plan Covers—Nonnetwork Services and Supplies,” on page 24

Covered Services and Supplies Network Provider* Nonnetwork Provider**• Inpatient and outpatient

combined maximum• $7,500 per course of treatment

• Lifetime maximum of two courses of treatment (network and nonnetwork combined)

• $2,500 per course of treatment


• Lifetime maximum of two courses of treatment (network and nonnetwork combined); accrues toward the $7,500 network maximum per course of treatment

Therapy (occupational, physical, and speech)

100%; limits may apply 60%; limits may apply

Vision care • Vision care benefi ts are managed by Vision Service Plan (VSP)

• See “Vision Care Program,” later in this booklet

• Eye examination (one every 12 months; network and nonnetwork combined)

• 100% after $15 copayment

• Deductible does not apply

• 100% up to $50

• Deductible does not apply

• Lenses (two pairs every two years)

• Single vision $50 allowance per pair

• Bifocal $80 allowance per pair

• Trifocal $95 allowance per pair

• Lenticular $155 allowance per pair

• Frames (two sets every two years)

$70 allowance per set

• Contact lenses (twice every two years in place of lenses and frames)

$105 allowance per supply

* The network payment level is based on the approved fees that the service representative negotiated for specifi c providers and services covered by the plan.

** The nonnetwork payment level is based on the reasonable and customary charge (as defi ned by this plan). You are responsible for paying any charges in excess of the amount the service representative determines to be the reasonable and customary charge.


Network Service AreaThe plan’s network service area is St. Louis and the surrounding counties. When you are a newly eligible employee or during the annual enrollment period, you will receive information indicating whether you live within the network service area and are eligible to enroll in the plan.

When you enroll in the UnitedHealthcare coordinated care plan, the plan pays the greatest level of benefi ts when you use covered medical services and supplies from network providers.

How Medical Expenses Are PaidNetwork Benefi tsThe plan pays the greatest level of benefi ts (100 percent after applicable copayments) when you obtain covered medical services and supplies from network providers. Additional network payment provisions and network benefi ts are described in this section.

Certain services are covered only with prior plan approval or when you use network providers.

Nonnetwork Benefi tsIf you live in the network service area and you obtain covered medical services or supplies from nonnetwork providers, your benefi t coverage will be much lower. In general, the plan pays 60 percent of reasonable and customary charges after you pay a $500 annual deductible per person. Additional nonnetwork payment provisions and nonnetwork benefi ts are described in this section.

Coverage for a Child Who Does Not Live With YouIf your dependent child lives away from home (for example, your child boards at college or lives with your former spouse), he or she must obtain services from a network provider to receive the network level of benefi ts. Contact the service representative for information about available coverage.

Coverage When You Are TravelingThe plan covers treatment for illnesses or injuries that occur while you are traveling (business or personal) outside the network service area. You will receive the network level of benefi ts only when you receive care from a network provider.

If you or a dependent will be out of the network service area for an extended period, check with the service representative to see what options are available to you for continuing care.

In a medical emergency, get treatment as soon as possible, just as you would if you were in the network service area.

For an unexpected urgent need that is not an emergency, you will receive network level of benefi ts by using a network provider.

The treating physician or hospital may require you to pay at the time of the service. In this case, add your health plan member identifi cation number to the bill for proper identifi cation, and then send the bill to the service representative at the address on your health care identifi cation card with a note to explain the circumstances. If you used an emergency room, include a copy of the emergency room report if you have one. You do not need a claim form.

If you go on a business trip of more than 90 days, you must use area network providers in order to receive the network level of coverage. Contact the service representative to see what options are available to you for continuing care.


Network Benefi t Payment Levels and MaximumsWhen you or your dependents obtain health care services in the network service area, the plan generally pays 100 percent for covered network services after applicable copayments or coinsurance.

Payment provisions for the mental health and substance abuse program, prescription drug program, and vision care program are described later in this booklet.

CopaymentsYou and your eligible dependents are responsible for paying copayment expenses before the plan will begin paying benefi ts. Your health care provider cannot waive copayment expenses.

Offi ce Visit CopaymentThe plan will pay 100 percent for covered outpatient visits to network providers after you pay the following copayments:

• A $10 copayment applies to each covered outpatient visit to a network provider, except as otherwise described.

• For pregnancy, you pay a copayment for the fi rst prenatal visit. All other prenatal and postnatal visits for that pregnancy are covered in full. However, if you change physicians during the pregnancy, you must pay a copayment for the fi rst visit to the new physician.

• No offi ce visit copayment is required when

• The sole purpose of the visit is to receive an allergy shot.

• The visit is for preventive care (see page 23).

Emergency Room CopaymentA $50 copayment applies to each visit to a hospital emergency room. After the copayment, the plan pays 100 percent for covered emergency services. The $50 copayment will be waived if the patient

• Is admitted as an inpatient immediately after emergency room treatment.

• Dies in the emergency room.

Lifetime Maximum Benefi tThere is no lifetime maximum benefi t for services and supplies obtained in and through the network.

Covered expenses under the separate prescription drug and vision care programs do not apply to your lifetime maximum benefi t under this plan. Covered nonnetwork expenses under the separate mental health and substance abuse program do apply to your nonnetwork lifetime maximum benefi t. (See information about the mental health and substance abuse, prescription drug, and vision care programs later in this booklet.)


Nonnetwork Benefi t Payment Levels and MaximumsIf you use a nonnetwork provider, the plan will pay less of the covered charges than if you had used a network provider. Nonnetwork providers are physicians, hospitals, and other medical professionals who do not have contracts with the service representative.

When you or your dependents obtain medical services from a nonnetwork provider, the lower, nonnetwork level of benefi ts applies.

You and your eligible dependents are responsible for paying deductible expenses before the plan will begin paying nonnetwork benefi ts. Your nonnetwork health care provider may not waive deductible expenses.

Annual DeductibleBefore the plan begins paying nonnetwork benefi ts during a calendar year, you must satisfy a deductible of $500 per person; there is no family deductible maximum. Covered expenses incurred in the last quarter of the calendar year that are applied to the deductible also are applied to the deductible for the next calendar year.

Any payments that you make for the following do not apply toward the deductible:

• Expenses above the reasonable and customary allowance.

• Charges for noncovered services and supplies.

• Any penalty you pay for inpatient hospital services obtained without preadmission certifi cation are not applied toward the deductible. (See page 17 for information about preadmission certifi cation.)

CoinsuranceCoinsurance means you and the plan each pay part of the cost of covered health care services. After you pay the deductible, the plan pays 60 percent and you pay 40 percent of reasonable and customary charges for covered nonnetwork services and supplies, up to the out-of-pocket expense limit (described next).

Different coinsurance provisions apply to mental health and substance abuse treatment. For details, see “Mental Health and Substance Abuse Program,” later in this booklet.

Out-of-Pocket Expense LimitFor certain services, you are required to pay 40 percent of covered charges (called your out-of-pocket expenses). Your responsibility is limited as follows. When your out-of-pocket expenses reach $3,000 in any calendar year, most additional benefi ts that would have been paid at 60 percent are paid at 100 percent of reasonable and customary allowances for the remainder of that calendar year, up to the maximum benefi t amounts.

Expenses that do not count toward the individual out-of-pocket expense limit are

• Offi ce visit copayments.

• The annual deductible.

• Hospital emergency room copayments.

• The difference between the reasonable and customary allowance and the provider’s actual charge.

• Any balance remaining after a benefi t maximum has been reached.

• Covered medical services paid at 100 percent of reasonable and customary charges or in full.


• Covered medical services for treatment of mental illness or substance abuse, prescription drugs, or vision care.

• Benefi ts paid at a reduced amount or denied when the patient fails to follow medical review program procedures and requirements.

• Expenses for services or supplies not covered by the plan.

Lifetime Maximum Benefi tThe lifetime maximum benefi t for all covered nonnetwork medical services and supplies is $1,500,000, subject to all other plan provisions. This maximum applies separately to each covered family member.

Covered expenses under the separate prescription drug and vision care programs do not apply to your lifetime maximum benefi t under this plan. Covered nonnetwork expenses under the separate mental health and substance abuse program do apply to your nonnetwork lifetime maximum benefi t.

The separate programs for mental health and substance abuse, prescription drugs, and vision care are described later in this booklet.

Other Medical ExpensesAmounts you pay for mental health and substance abuse treatment, prescription drugs, and vision care do not apply to the annual deductible or out-of-pocket expense limit. Expenses for prescription drugs and vision services do not apply to the lifetime maximum benefi t.

The separate programs for mental health and substance abuse, prescription drugs, and vision care are described later in this booklet.

Reasonable and Customary AllowancesAs do most medical plans, this plan pays benefi ts based on reasonable and customary allowances for covered expenses. The service representative determines the reasonable and customary allowance based on the 90th percentile of the charges for the same or similar services within a geographic area. Generally, this means that 90 percent of the physicians who perform a service in a geographic area charge the reasonable and customary amount or less. Fewer than 10 percent of the physicians charge more than the reasonable and customary allowance.

If the charges submitted to the plan are more than the reasonable and customary allowance for a particular service, the plan will pay your benefi t based only on its reasonable and customary allowance for that service. You must pay any amount that exceeds the reasonable and customary allowance.

Advance Estimate of Reasonable and Customary AllowanceYou can avoid incurring a charge that exceeds the reasonable and customary allowance by taking the following steps:

• Ask ahead of time what the charge will be (for example, when you make an appointment).

• If the proposed charge is more than $200, ask your physician to complete an Advance Reasonable and Customary Estimation form describing the service. You can get the form from the service representative.

• Submit the completed Advance Reasonable and Customary Estimation form to the service representative.


The service representative will tell you whether or not the charge is within the reasonable and customary allowance for that service. If the charge is more than the reasonable and customary allowance, you will be told how much it exceeds the allowance.

Medical Review Program for Nonnetwork HospitalizationWhen you live in a network service area and decide to manage your own medical care, you must follow these special benefi t provisions.

Preadmission Certifi cationPreadmission certifi cation is not required for hospital admissions outside the United States. A separate preadmission process is required for mental health and substance abuse treatment; for more information, see page 28.

If your nonnetwork physician recommends an overnight hospital stay for you or a covered family member, you will be responsible for getting preadmission certifi cation. Under preadmission certifi cation, a medical reviewer must certify the need for hospitalization. This is another way of ensuring that you obtain the most appropriate medical care at a reasonable cost.

To begin the certifi cation process, the patient, a family member, or the physician must call the telephone number on your health care identifi cation card before any nonemergency admission.

After receiving the required information, a qualifi ed medical reviewer will match the patient’s diagnosis with the physician’s treatment plan. Based on nationally accepted criteria and the information that the physician presents, the medical reviewer will decide whether or not the hospital is the best place to provide treatment for the patient.

If the medical reviewer determines that the patient’s condition can be treated just as well elsewhere (for example, in a physician’s offi ce or an outpatient surgical center), hospitalization will be judged unnecessary and inappropriate.

Hospital preadmission review for childbirth is not required for a mother or newborn for the fi rst 48 hours after a normal delivery or 96 hours after a cesarean section.

If the nonemergency hospitalization is certifi ed as necessary and appropriate, the plan will pay normal nonnetwork benefi ts for hospital services. However, if certifi cation is not requested on a timely basis, or if it is requested but is not approved and you incur inpatient hospital expenses, then the plan will reduce covered expenses for room and board charges by 20 percent before calculating the benefi t.

The penalty you pay as a result of the reduction in room and board benefi ts will not exceed $750 per hospitalization. The penalty will not apply to your annual deductible or out-of-pocket expense limit.

In an emergency situation (as defi ned on page 49), the patient can and should be admitted to the hospital without delay. Then, the patient, a family member, the physician, or the hospital must call the telephone number on your health care identifi cation card as soon as reasonably possible. (Remember, the plan covers emergency treatment under network benefi t provisions no matter when or where the emergency occurs, provided that you call your service representative.)

Continued Stay ReviewOnce the patient has been admitted to the hospital, the need to stay there must also be certifi ed. You do not have to do anything to initiate the continued stay review. Instead, the medical reviewer will monitor the patient’s time in the hospital. The medical reviewer will notify you in writing when, in the medical reviewer’s opinion, further hospitalization becomes unnecessary.


The medical reviewer’s notice does not necessarily mean you are considered well. Rather, the notice indicates that any additional care can be provided in a convalescent and long-term illness care facility, by a hospice program, in the physician’s offi ce, or at home.

Normally, this notice is advisory and will not affect your benefi ts. However, if care becomes custodial in nature, the plan no longer will cover the stay.

Medical Case ManagementThe plan offers medical case management as a service to a patient who has an illness or injury that requires rehabilitation or other long-term health care support. You do not pay for medical case management services.

Although your decision to participate is entirely voluntary, medical case management can result in improved services for your benefi t dollar.

During the preadmission certifi cation process (described on the previous page), the medical reviewer will become aware of any potential need for long-term care and will refer the case to a medical case manager for evaluation. If the evaluation shows that medical case management could be benefi cial, the medical case manager will contact the patient (or responsible family member) regarding participation.

At no charge to you, medical case management provides personal counseling by experienced health care professionals. These medical case managers work with the physician to evaluate, among other things, the diagnosis, expectations for recovery, the plan of care, and alternative forms of treatment.

If the patient needs special medical supplies and equipment, physical therapy and rehabilitation, outpatient treatment, and the like, the medical case manager will help arrange for them. The purpose is to improve the quality of care and reduce its cost by minimizing the time spent in the hospital.

If the patient’s physician and medical case manager prescribe alternative forms of treatment that normally are not covered by the plan, the service representative must approve the alternative before the patient incurs the expense.

What the Medical Plan Covers—Network Services and SuppliesIn general, the plan covers medically necessary services and supplies when they are used to diagnose or treat a nonoccupational accidental injury or illness. Medically appropriate services and supplies generally are covered for certain preventive care and for other listed conditions, up to plan limits.

Coverage of the following services and supplies is subject to general plan provisions, including the noncovered services and supplies (described beginning on page 25) and the defi nitions (beginning on page 48).

Emergency and Urgent CareEmergency room treatment at either a network or nonnetwork facility is paid at the network level when it is a true medical emergency. However, if a patient receives emergency room treatment at a network or nonnetwork facility when the condition is not a true medical emergency, covered services will be paid at the nonnetwork level. (See page 49 for the defi nition of an emergency.)


When the need for care is urgent but does not require emergency room treatment, call your physician or the number on your health care identifi cation card before you receive care.Your physician may suggest you go to his or her offi ce, an urgent care facility, or an emergency room. These same guidelines apply when you are out of the network service area.

Hospital AlternativesThe plan covers the following hospital alternatives:

• Convalescent and long-term illness care facility services.

• Home health care services, including skilled nursing care and other services that are provided by a network home health care agency (excluding custodial services such as meal preparation, personal comfort items, housekeeping, and other services that are not treatment of the medical condition).

• Hospice care. A hospice program provides a group of interdisciplinary services designed to meet the physical, psychological, spiritual, and social needs of dying persons and their families. These services, including pain control and supportive medical, nursing, mental health, and other health services, may be provided by the following network providers:

• A hospital.

• A skilled nursing facility or a similar institution.

• A home health care agency.

• A hospice facility.

• Any other facility or agency licensed to provide hospice care services.

• Outpatient hospital or ambulatory surgical center services and supplies.

• Skilled nursing facility care (except for custodial care and conditions of senile deterioration, mental retardation, and mental illness).

Hospital Services and SuppliesThe plan covers the following inpatient hospital services and supplies:

• Professional services, including the services of attending physicians, anesthesiologists, pathologists, radiologists, and nurses. Private-duty nursing is covered only when approved by the service representative in advance.

• Room and board for services provided in a ward, semiprivate room, operating room, intensive care unit, or other special care unit.

• Supplies for treatment, including whole blood or blood components, oxygen, ordinary casts, splints, dressings, and prescription drugs and medicines used while in the hospital.

Hospital Stay Rules for Mothers and NewbornsGroup health plans and health insurance issuers generally may not, under Federal law, restrict benefi ts 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 cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).


Medical Services and SuppliesThe UnitedHealthcare coordinated care plan covers the following medical services and supplies:

• Ambulance services from the scene of an injury or medical emergency and for whom an ambulance is medically necessary.

• Anesthesia.

• Autologous blood donation (elective harvesting and storage of blood from the member in anticipation of surgery).

• Chiropractic services, including the initial diagnostic laboratory work and X-rays.

• Consumable supplies, as follows:

• Catheters, including indwelling, intermittent, and external.

• Ostomy supplies.

• Irrigation kits.

• Jobst pressure garments for burn victims.

• Jobst full-length stockings for vascular problems.

The plan does not cover other over-the-counter supplies.

• Contraceptive injections, implants, and intrauterine devices (IUD).

• Dental services, covered when approved in advance by the service representative, as follows:

• Hospital charges in connection with dental treatment when hospitalization is required because of a concurrent medical condition.

• Treatment of sound natural teeth injured when medically necessary and required for the prompt repair of an accidental injury, whether or not the accidental injury occurred while the person was covered under the Company-sponsored plan, provided that the treatment is received within 12 months of the accident.

• Treatment of temporomandibular joint (TMJ) syndrome.

• Diagnostic services, laboratory services, and X-ray examinations.

• Durable medical equipment. The plan covers the use of certain durable medical equipment when it is prescribed by a network physician, obtained from a network provider, and meets all of the following criteria. The equipment

• Can withstand repeated use.

• Is used to serve a medical purpose.

• Is generally not useful to a person in the absence of a sickness or injury.

• Is appropriate for use in the home.

Examples of covered durable medical equipment include

• Braces to stabilize an injured body part, including necessary adjustments to shoes to accommodate braces. (Dental braces are not covered.)

• Delivery pumps for tube feedings, including tubing and connectors.

• Equipment to assist mobility, such as a standard wheelchair, when prescribed by a network physician and obtained from a network provider. The plan covers wheelchair replacements when required because of a change in physical condition or normal wear and tear.


• Mechanical equipment necessary to treat chronic or acute respiratory failure (except that air conditioners, humidifi ers, dehumidifi ers, air purifi ers and fi lters, and personal comfort items are not covered).

• Oxygen and the rental of equipment to administer oxygen (including tubing, connectors, and masks).

• A standard hospital-type bed.

For a list of equipment the plan currently does not cover, see the personal comfort and convenience items or services information on page 26.

• Erectile dysfunction. The plan covers treatment of organic erectile dysfunction when the patient has a history of one or more of the following:

• Peripheral vascular disease or local penile vascular abnormalities.

• Peripheral neuropathy or autonomic insuffi ciency.

• Prostate cancer.

• Spinal cord disease or injury.

• Major pelvic surgery.

• Insulin-dependent diabetes appearing before age 50.

• Severe Peyronie’s disease.

Covered therapy includes vacuum erection devices, injection therapy, a penile prosthesis, urethral pellets, and prescription medications (as covered under the prescription drug program).

The plan does not cover treatment for nonorganic impotence such as psychosexual dysfunction.

• Family planning services, including counseling, vasectomy, and tubal ligation.

• Genetic counseling and procedures necessary to determine the existence of gender-linked genetic disorders. (Amniocentesis, ultrasound, or any other procedures, when used solely for sex determination of a fetus, are not covered.)

• Hair prostheses (wigs) are covered as of January 1, 2005, for hair loss resulting from cancer treatment.

• Hearing aid services and repairs. The plan covers one otological and audiometric examination from an audiologist and one standard hearing device per ear during a three-year benefi t period.

• Infertility diagnosis and treatment. The plan covers services for the diagnosis and treatment of infertility, except for drugs, injectables, and procedures (such as in vitro fertilization) that bypass, rather than treat, a functional abnormality.

• Intravenous therapy and antineoplastics.

• Medical supplies and equipment for the treatment of type 2 diabetes. This includes blood glucose monitors (including those designed to assist the visually impaired), insulin pumps and all related necessary pump supplies, podiatric devices to prevent or treat diabetes-related complications, and visual aids (excluding eyewear) to assist the visually impaired with the proper dosing of insulin.

• Nutritional evaluation. The plan will cover nutritional evaluation and counseling if your physician determines that diet is a part of your medical treatment.

• Orthopedic and prosthetic devices, including replacement when due to a change in physical condition or wear and tear.


• Orthotics or other supportive devices for the feet when prescribed for the treatment of an injury or other medical condition of the foot. These devices may include braces, splints, insoles, and foot supports constructed of acrylic, plastic, or metal as well as impression casts required for the fi tting of these devices. The device must be intended for wear at all times that shoes are worn and not just for specifi c activities. The plan does not cover shoes or supports that are available without prescription.

• Peak fl ow meters for the treatment of asthma, if medically necessary.

• Physical therapy, speech therapy, and occupational therapy, but only when the services are restorative and signifi cant improvement can be expected in a short time (such as within two months).

• Reconstructive breast surgery. If you have had or are going to have a mastectomy, you may be entitled to certain benefi ts under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefi ts, coverage will be provided in a manner determined in consultation with the attending physician and the patient for

• 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.

• Treatment of physical complications of the mastectomy, including lymphedemas.

These benefi ts will be provided subject to the same deductible, copayment, and coinsurance applicable to other medical and surgical benefi ts provided under this plan.

• Transplant benefi ts. The plan covers medically necessary services and supplies related to covered transplants. Transplants that are part of an approved clinical trial also may be covered. Contact the service representative for more information about covered services and supplies.

When the recipient is covered by this plan, the plan considers the covered expenses of both the recipient and the donor, whether or not the donor is covered by this plan.

The plan considers expenses for the following services for obtaining a donor organ:

• Acquisition or cost of an organ from a deceased donor.

• Compatibility testing of any deceased or live donor.

• Surgery and hospital expenses for removing the organ from a live donor.

The plan does not cover the following:

• Donor and procurement services and costs incurred outside the United States, unless specifi cally approved by the service representative.

• Expenses for that portion of treatment funded by government or private entities as part of an approved clinical trial. Contact the service representative for more information.

• Expenses when the recipient is not covered under this plan.

• Experimental or investigational services or supplies, unless they are part of an approved clinical trial. Contact the service representative for detailed information.

• Living (noncadaver) donor transplants (except kidney, liver, lobar lung, and bone marrow or stem cell transplants for covered conditions), including selective islet cell transplants of the pancreas.

• Lodging, food, or transportation costs, unless otherwise specifi cally provided under this plan.


• Nonhuman, artifi cial, or mechanical transplants.

• Services and supplies for the donor when donor benefi ts are available through other group coverage.

• Transportation services, as follows:

• An ambulance for emergency transportation to and from the nearest hospital able to provide appropriate care.

• Transportation (to and from the transplant center for a live donor; to the transplant center for an organ from a deceased donor) in connection with a covered transplant when the donor is not in the transplant center area.

• Nonemergency use of an ambulance when recommended by your network physician and approved in advance by the service representative.

• Transportation to and from a provider outside of the network service area, but only when the service representative determines special treatment is not available in the network service area.

Physician ServicesThe plan covers the services of a licensed physician for the medically necessary diagnosis or treatment of nonoccupational accidental injuries, illnesses, or other covered conditions.

Physician services also are covered for injectable legend drugs used to treat a covered condition and administered in a physician’s offi ce. (Preventive injections and immunizations are not covered, except as noted in the preventive care benefi t described in this section.) Medical devices (including contraceptive injections and implants) that are dispensed by a physician are covered.

An eye examination (including refraction) is covered when performed because of another medical condition such as diabetes, glaucoma, or cataracts. (Routine eye examinations are covered under the vision care program, which is described later in this booklet.)

Preventive CareYour physician will advise you of the preventive care services that are medically indicated for you based on your age, sex, and medical history. Generally, the following services are covered:

• Pediatric examinations and well-baby care as recommended by American Academy of Pediatrics guidelines.

• Routine childhood immunizations as recommended by American Academy of Pediatrics and U.S. Centers for Disease Control and Prevention guidelines.

• Immunizations in accordance with accepted medical practice. (The plan does not cover immunizations required or recommended by third parties for employment, fl ight clearance, summer camp, insurance, foreign travel, or similar reasons.)

• Health assessments and examinations.

• Periodic mammograms.

• A well-woman examination, including a Pap test and mammogram (if indicated). Once each calendar year, the plan allows a woman to obtain a well-woman examination from a network obstetrician or gynecologist. Mammograms are provided at imaging facilities specifi ed by the service representative.

• Vision screening from an ophthalmologist or optometrist, except eye refraction examinations that are covered under the vision care program. (See page 35.)


How to Submit a Network Medical ClaimWhen you obtain care from a network provider, you generally do not need to fi le claim forms. If you receive emergency care outside the network service area, you must pay for the service and fi le a claim form for reimbursement. Claim forms are available from the service representative. Claims must be submitted to the service representative within 12 months from the date you received medical services or supplies.

What the Medical Plan Covers—Nonnetwork Services and SuppliesYou and your dependents are entitled only to covered services and supplies that the plan determines to be medically necessary.

Unless stated otherwise, the lists of covered network services and supplies and exclusions also apply to nonnetwork benefi ts.

When you choose to receive nonnetwork services, the plan does not pay for preventive care services, transplant benefi ts, or hearing aid benefi ts. You are responsible for obtaining preadmission certifi cation for inpatient hospital stays and must pay up to an additional $750 if you fail to do so. In addition, the plan places special limits on chiropractic care and skilled nursing facility care.

The following special coverage provisions apply to nonnetwork benefi ts.

AcupunctureThe plan covers acupuncture only under nonnetwork benefi t provisions and only when the services are provided by a person licensed to practice acupuncture. No network benefi ts are available.

Christian Science TreatmentThe plan covers treatment by a Christian Science practitioner, nurse, and sanatorium onlyunder nonnetwork benefi t provisions. No network benefi ts are available.

The practitioner, nurse, and sanatorium must be authorized as such by the Mother Church, the First Church of Christ, Scientist, of Boston, Massachusetts.

Skilled Nursing FacilityThe plan pays nonnetwork benefi ts for services received in a nonnetwork skilled nursing facility (except for custodial care and conditions of senile deterioration, mental retardation, or mental illness). Admission to the facility must be within 14 days after release from a hospital stay of at least 3 days or within 14 days of a previous confi nement in a nursing home.

How to Submit a Nonnetwork Medical ClaimWhen you obtain nonnetwork services you generally must pay for the services and then fi le a claim for reimbursement. Claim forms are available from the service representative. Complete the claim form and attach an itemized bill that clearly identifi es the patient, dates of service, types of services, and the charges. Submit the claim as instructed on the form, and be sure to keep a copy of all itemized bills for your records. Claims must be submitted to the service representative within 12 months from the date you received medical services or supplies.


What the Medical Plan Does Not Cover—Network or Nonnetwork Services and SuppliesThe plan does not cover the following services and supplies, whether obtained through network providers or through nonnetwork providers, except as specifi cally noted:

• Acupuncture, except as described on page 24.

• Amniocentesis, ultrasound, or any other procedures when used solely for sex determination of a fetus, except that genetic counseling and procedures necessary to determine the existence of gender-linked genetic disorders are covered.

• Any accident or illness covered by a workers’ compensation law.

• Appearances in court or at a hearing.

• Artifi cial insemination, in vitro fertilization, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer, or similar procedures that bypass, rather than treat, a functional abnormality.

• Care while in the custody or care of a government agency (for example, a correctional agency) or while under the authority of a court order.

• Charges by a physician, nurse, or other medical practitioner who is a close relative or who lives with the covered individual.

• Christian Science treatment, except as described on page 24.

• Commercial weight loss programs.

• Conditions that state or local law requires to be treated in a public facility.

• Confi nement; surgical, medical, or other treatment, services, or supplies received in or from a U.S. Government hospital, except as required by law.

• Cosmetic surgery or any other surgical procedure that is primarily for the purpose of altering appearance. However, surgery that restores a normal bodily function or surgery that is medically necessary is covered.

• Costs associated with the collection, preparation, or storage of sperm for artifi cial insemination, including donor fees.

• Court-ordered treatment or hospitalization, unless the order is being sought by a network physician or unless the plan normally would cover it without the court order.

• Custodial or domiciliary care, rest cures, or transportation for such care.

• Dental or orthodontia services, except those noted on page 20.

• Expenses in excess of reasonable and customary charges, as determined by the service representative.

• Expenses that you are not legally obligated to pay.

• Experimental, investigational, or unproven services, which are medical, surgical, psychiatric, substance abuse, or other health care technologies, supplies, treatments, procedures, drug therapies, or devices that are determined by the service representative to be

• Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not recognized for the treatment of the particular indication in one of the standard reference compendia (the United States Pharmacopeia Drug Information, the American Medical Association Drug Evaluations, or the American


Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientifi c studies published in a peer-reviewed, national professional journal.

• The subject of review or approval by an institutional review board for the proposed use.

• The subject of an ongoing clinical trial that meets the defi nition of a phase I, II, or III clinical trial as set forth in the FDA regulations, regardless of whether the trial is subject to FDA oversight, except as provided by this plan.

• Not demonstrated, through existing peer-reviewed literature, to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed.

• Hearing aid care, services, or supplies for

• Altering of hearing aid equipment.

• Expenses incurred for a hearing aid after the termination of coverage, except for hearing aids ordered before termination and delivered within 30 days after termination.

• Replacement batteries or any other ancillary equipment obtained after the hearing aid is purchased.

• Medical or surgical services for the treatment or control of obesity, unless medically necessary.

• Mental health or substance abuse treatment or testing covered under the mental health and substance abuse program. For coverage information, see “Mental Health and Substance Abuse Program,” later in this booklet.

• Naturopathy or hypnotherapy.

• Outpatient prescription drugs or other supplies that are covered under the prescription drug program. (For coverage information, see “Prescription Drug Program,” later in this booklet.)

• Over-the-counter disposable or consumable supplies (except those noted on page 20).

• Personal comfort or convenience items or services, including but not limited to

• Assistance in daily living activities such as eating, bathing, dressing, or services primarily for rest, domiciliary, or custodial care.

• Bathtub chairs, safety grab bars, stair gliders, elevators, over-the-bed tables, saunas, or exercise equipment.

• Environmental control equipment such as air purifi ers, humidifi ers, or electrostatic machines.

• Equipment used for athletic activities, including braces or splints.

• Hygienic or self-help items or equipment.

• Institutional equipment such as air-fl uidized beds or diathermy machines.

• Items not accepted by the medical profession as being therapeutically effective such as auto-tilt chairs, paraffi n bath units, or whirlpool baths.

• Meal preparation or housekeeping services in connection with home health care.

• Television, telephone charges, guest meals, or cots for overnight guests while an inpatient.

• Physical examinations, immunizations, or diagnostic testing required or necessitated by third parties for employment, fl ight clearance, summer camp, insurance, foreign travel, or similar reasons.


• Physical therapy, speech therapy, or occupational therapy if not restorative or if the continued therapy will not show evidence of signifi cant continued improvement.

• Radial keratotomy, vision therapy, eye examinations, lenses, or frames for the correction of vision defi ciencies. (See “Vision Care Program,” later in this booklet.)

• Replacement or repair of lost, stolen, or willfully damaged artifi cial limbs, eyes, or braces for the arm, leg, back, or neck.

• Routine trimming of nails, calluses, or corns unless medically necessary.

• Services for which no charge is made or for which you are not, in the absence of this plan, legally obligated to pay.

• Services or supplies the service representative determines are not medically necessary and appropriate for the therapeutic treatment of an illness, injury, or pregnancy, except for certain preventive care and hospice care as authorized by the service representative.

• Services or supplies to the extent they are covered under any Federal, state, or other government plan, except where required by law.

• Sex-change surgery, presurgery counseling, or hormone therapy.

• Skilled nursing care for conditions of senile deterioration, mental retardation, or mental illness.

• Special medical reports not directly related to treatment.

• Treatment of an injury or illness arising out of the course of employment.

• Tuboplasty or reversal of voluntary sterilization.

• Vocational or educational testing and/or therapy.

What the Medical Plan Does Not Cover—Nonnetwork Services and SuppliesIn addition, the plan will not pay benefi ts under nonnetwork provisions for the following nonnetwork provisions for the following nonnetworkservices and supplies:

• Medical expenses incurred to the extent the provider gives a discount, credit, or reduction to the covered individual.

• Nutritional evaluations or counseling sessions.

• Preventive care. (The preventive care services available through your network physician are described on page 23.)

• Routine trimming of nails, calluses, or corns. (These services may be covered under network benefi ts when recommended by your physician as necessary because of a concurrent medical condition.)


Mental Health and Substance Abuse ProgramThis program offers you and your dependents the opportunity to talk with trained professionals who will help you fi nd appropriate care for mental illness or substance abuse. You can contact the program by calling the ValueOptions telephone number on your health care identifi cation card. The program is strictly confi dential.

The program covers medically necessary treatment of mental illness (including eating disorders) and substance abuse. When treatment is provided through a ValueOptions network provider, the plan payment level is higher. You can get a referral to a network provider by following the assessment and referral process described below.

The mental health and substance abuse program is administered by ValueOptions (the service representative). The Company may change the service representative at any time.

Assessment and Referral ProcessTo receive the greatest benefi ts from the program, you must begin all nonemergency treatment for mental health and substance abuse by completing a confi dential assessment and referral process. To receive network benefi ts, you must receive treatment from a ValueOptions network provider. All network providers are responsible for having ValueOptions review the care for medical necessity.

To initiate the assessment and referral process, call ValueOptions.

In an emergency, obtain the necessary emergency care and then call (or have a family member or your provider call) within 48 hours of receiving the emergency care to initiate the assessment and referral process.

Once you have started the assessment and referral process, the case manager will provide ongoing support and management for your treatment.

Payment ProvisionsWith Assessment and ReferralWhen you follow the assessment and referral process described above, the following payment provisions apply to treatment of mental health, substance abuse, or a combination of the two:

• There is no annual deductible.

• The program pays 100 percent of charges for certifi ed inpatient care.

• You pay a $10 copayment for each certifi ed outpatient visit.

Without Assessment and ReferralIf you choose to obtain your care through a nonnetwork provider, there will be no case management through ValueOptions, and the following payment provisions will apply.

You must pay an annual deductible of the fi rst $500 of the reasonable and customary allowance for covered mental health or substance abuse treatment. The $500 deductible applies to each covered person. There is no family deductible maximum. The deductible for mental health and substance abuse treatment is separate from the coordinated care plan deductible.


Without assessment and referral, the plan pays reasonable and customary expenses as described here.

Mental Health Treatment After you pay the deductible, the program pays

• 60 percent of charges for covered inpatient hospital care, including partial hospitalization, for up to 20 days per calendar year. Each 2 days of partial hospitalization reduces the 20 days available for inpatient care by 1 day.

• 60 percent of charges for a covered intensive outpatient care program for treatment of mental illness (if available in your area). Each 4 days of intensive outpatient care reduces the 20 days available for inpatient care by 1 day.

• 60 percent of charges for covered outpatient care for up to 20 visits per calendar year.

You are responsible for all charges that the program does not pay. There is no coverage for residential treatment centers without referral and assessment by ValueOptions.

For additional mental health benefi t limits, see “Lifetime Maximum Benefi t,” earlier in this booklet.

Substance Abuse Treatment After you pay the deductible, the program pays

• 60 percent of charges for covered inpatient hospital care. The maximum benefi t payable is $200 per day for up to 20 days per calendar year.

• 60 percent of charges for a covered intensive outpatient care program for treatment of substance abuse (if available in your area). Each 4 days of intensive outpatient care reduces the 20 days available for inpatient care by 1 day.

• 60 percent of charges for covered outpatient care for up to 20 visits per calendar year.

You are responsible for all charges that the program does not pay.

Lifetime Maximum Benefi tMental Health TreatmentCovered nonnetwork expenses apply to your nonnetwork medical lifetime maximum benefi t, which is described on page 16.

Substance Abuse TreatmentEach covered person is eligible for two courses of substance abuse treatment in a lifetime, whether or not that person uses the assessment and referral process. Network provider benefi ts are limited to $7,500 per course of treatment. Nonnetwork provider services are limited to $2,500 per course of treatment.

The following events are considered to be a course of treatment under the program:

• Completion of intensive care (with or without detoxifi cation) and the one-year aftercare program.

• Detoxifi cation, without continued treatment after detoxifi cation.

• Partial completion of the intensive phase of treatment (with or without detoxifi cation).

• Completion of the intensive phase of treatment but not the one-year aftercare program.

If a person suffers a relapse after ending any one of these courses of treatment, any new treatment will be considered a second course of treatment under this program.


What the Plan Covers Mental Health Treatment (Including Eating Disorders) The plan covers the medically necessary treatment of mental illness. The following types of providers are eligible for reimbursement under the plan:

• Any provider contracted with ValueOptions.

• A licensed clinical psychologist.

• A licensed hospital or treatment facility.

• A licensed psychiatric doctor (M.D.).

• A licensed psychiatric nurse (R.N.).

• A professional at the master’s level or above who is licensed in the area where the services are provided.

If the mental illness is related to, accompanies, or results from substance abuse, coverage of the treatment will be provided solely under the substance abuse provisions.

Substance Abuse Treatment The plan covers the following substance abuse treatments and services:

• Medically necessary treatment for alcoholism.

• Other types of substance abuse treatment at an approved treatment facility or hospital.

• The services of a physician and licensed therapist.

• Prescription drugs in connection with your physician’s specifi c treatment plan.

An approved substance abuse treatment facility is one that treats chronic alcoholism and/or drug abuse that is licensed and regulated by the appropriate governmental agency in its location.

The plan covers detoxifi cation only when it is followed immediately by rehabilitation. To receive coverage for substance abuse treatment, the patient must complete the prescribed course of treatment.

How to Submit a Mental Health or Substance Abuse ClaimWhen you follow the assessment and referral process and receive care from a ValueOptions network provider, you are not responsible for fi ling the claim forms. The network provider will submit claims to ValueOptions on your behalf.

When you obtain care without a referral from ValueOptions, you generally must pay for the services and then fi le a claim for reimbursement. Claim forms are available from ValueOptions. Complete the claim form and attach an itemized bill that clearly identifi es the patient, dates of service, types of service, and charges. If the patient is your dependent and you are not identifi ed on the bill as an employee of the Company, include your name and Social Security number on the bill. Submit the claim as instructed on the form and keep a copy of all itemized bills for your records.


Prescription Drug ProgramThe prescription drug program offers two options for prescription drugs and medicines. You and your dependents may obtain a covered prescription through a local participating pharmacy using your pharmacy identifi cation card. As an alternative, you and your dependents can use the mail service program to order covered prescription drugs. A formulary applies to the prescription drug program. This section describes each option.

Generally, prescription drugs purchased at a nonparticipating pharmacy are not covered by this program.

The prescription drug program is administered by Medco Health Solutions, Inc. (the service representative). The Company may change the service representative at any time.

Certain dosages, quantities, and medications require preapproval by the service representative. If your prescription exceeds the Federal or clinically recommended dosage or quantity limits or is prescribed for a certain condition, your prescription may be denied. In this case, you must send the service representative a letter from your doctor providing clinical information, which will initiate the preauthorization process.

The service representative will apply standards based on FDA-approved labeling and clinical guidelines. The service representative ensures that you receive the most appropriate prescription for your condition by reviewing

• Possible interactions with other current prescriptions.

• Cost-effectiveness.

• Whether the prescription is age appropriate.

• Whether the dosage and quantity are appropriate.

In certain situations, it may be more clinically appropriate to take a stronger dose once a day than to take a lower dose twice a day. If this opportunity exists, the service representative may ask your physician to approve the changes to the dosage and strength before authorizing payment with your pharmacist.

Formulary A formulary is a list of a wide range of medications that are manufactured by major drug companies and approved by the FDA. An independent group of practicing physicians and pharmacists developed the list to include safe and effective medications. The formulary list may change from time to time. Lower copayments apply to formulary prescription drugs.

CopaymentsUnder the prescription drug card program, the following copayments apply to each covered prescription or refi ll purchased at a participating pharmacy:

• $5 for generic drugs.

• $15 for brand-name formulary drugs.

• $30 for brand-name nonformulary drugs.


Under the mail service program, the following copayments apply to each covered prescription or refi ll purchased through the mail service pharmacy:

• $10 for generic drugs.

• $30 for brand-name formulary drugs.

• $60 for brand-name nonformulary drugs.

The medical plan annual deductible does not apply to prescription drugs.

Maximum QuantityUnder the program, the maximum drug quantity for one copayment is a

• 30-day supply when purchased from a participating pharmacy.

• 90-day supply when purchased through the mail service program.

How to Fill a PrescriptionParticipating PharmacyGenerally, you must obtain your prescriptions through a local participating pharmacy to receive benefi ts for your prescription drug purchases. Contact Medco Health to fi nd participating pharmacies in your area.

To obtain your prescription, take your pharmacy identifi cation card and the prescription to the pharmacy. If the prescription is for a dependent, you will need to provide the dependent’s date of birth. If you do not present your identifi cation card, you must pay the full cost of the prescription and fi le a claim for reimbursement.

The pharmacist automatically will fi ll your prescription with a generic drug, if available, unless your physician has specifi cally stated that only a brand-name drug should be used. If you request a brand-name drug when a generic drug is available, you must pay the generic copayment plus the cost difference between the generic and brand-name drugs.

The applicable copayment is required at the time of purchase. (See “Copayments,” on page 31.) The prescription drug program will pay the balance of the cost.

Nonparticipating PharmacyIn most cases, no prescription drug program benefi ts are available when you use a nonparticipating pharmacy. There are two exceptions:

• You have an emergency outside your pharmacy’s normal hours.

• You are traveling and unable to locate a participating pharmacy or you are outside the United States.

In these situations, you must pay the full cost of the prescription and fi le a claim for reimbursement on a Medco Health claim form. Claim forms are available on request from Medco Health.

Mail Service ProgramThe mail service program—called Medco By Mail— allows you to purchase up to a 90-day supply of a medication prescribed by your physician. You pay only one copayment for each prescription or refi ll.

Medco Health generally will deliver your prescription by U.S. Mail or United Parcel Service within 14 days of your order.


To order a prescription by mail, follow these steps:

• Ask your physician to prescribe up to a 90-day supply of your medication, plus necessary refi lls.

• Obtain an order form from Medco Health.

• Mail the original prescription, the order form, and your payment to Medco Health in the return envelope.

• To order a refi ll of a prescription currently on fi le with Medco Health, call Medco Health or order through its web site.

When ordering drugs by mail, keep in mind that

• Some controlled substances are subject to special limitations. The pharmacist will tell you if your prescription cannot be fi lled as written.

• The pharmacist may not dispense some prescriptions in a 90-day supply because they come in a prepackaged form.

Covered Drugs The prescription drug program covers drugs and medicines that meet all of the following qualifi cations:

• The prescription is written by a physician, dentist, or other professional who is licensed to prescribe drugs.

• The prescription is dispensed by a licensed pharmacy.

• The drug is a legend drug, which means that Federal law requires it to bear the legend “Caution: Federal Law Prohibits Dispensing Without a Prescription,” or it is one of the following:

• A compound medication in which at least one ingredient is a legend drug.

• Contraceptive devices (cervical caps, diaphragms).

• Needles, syringes, and alcohol swabs in conjunction with a prescription for injectable insulin. Lancets and test strips are covered at 100 percent (network or nonnetwork).

• Oral or injectable insulin dispensed only with a physician’s written prescription.

What the Prescription Drug Program Does Not CoverThe program does not cover the following drugs and services, except as specifi cally noted:

• Antiobesity medications.

• Any drug that is not medically necessary (except the program covers prescription smoking deterrents and contraceptives regardless of medical necessity).

• Drugs given to the patient by the physician who prescribes them.

• Drugs labeled “Caution—Limited by Federal Law to Investigational Use” or drugs used as an experiment.

• Drugs or injectable insulin provided by a hospital, convalescent or long-term illness care facility, or similar facility while confi ned.

• Drugs or injectable insulin purchased in a quantity greater than prescribed by the physician or more than one year after the date of the prescription.


• Drugs prescribed for treatment of sickness covered under a workers’ compensation law, occupational disease law or similar law, or for treatment of injury if it arises out of or in the course of employment.

• Drugs, supplements, or supplies purchased over the counter.

• For covered prescriptions from a nonparticipating pharmacy, the cost in excess of what the program would have paid if you had used a participating pharmacy.

• Healing devices, immunization agents, blood or blood plasma, health or beauty aids, or delivery charges; however, medical devices (including contraceptive injections, devices, and implants) dispensed by a physician are covered under the UnitedHealthcare coordinated care plan.

• Injectables that are covered under the medical plan.

• Lost or misplaced prescription drugs.

• Part of a single purchase of a drug that exceeds a

• 30-day supply from a Medco Health participating pharmacy.

• 90-day supply under the mail service program.

• Prescriptions from a nonparticipating pharmacy, with the following exceptions:

• You have an emergency outside your pharmacy’s normal hours.

• You are traveling and unable to locate a participating pharmacy or you are outside the United States.

• Services or supplies that are covered under the medical plan.


Vision Care ProgramRoutine vision care services are offered through Vision Service Plan (VSP, the service representative). The Company may change the service representative at any time.

The vision care program pays a scheduled amount for the following vision benefi ts:

• One routine eye examination every 12 months.

• Two sets of frames and lenses (or two sets of contact lenses) every two years.

How to Obtain Vision ServicesVSP features a national network of licensed optometrists and ophthalmologists. These providers have contracted with VSP to provide vision care services and supplies. Although you may receive care from any covered licensed provider, the program offers you certain advantages when you use a VSP doctor.

VSP doctors offer discounts on complete pairs of prescription glasses and on contact lens examinations (evaluation and fi tting). The plan pays the VSP doctor the amounts shown in “Benefi t Payment Levels,” on page 36. You pay the excess of such amounts. VSP doctors also will submit your claims to the service representative.

For a list of VSP doctors, visit the VSP web site or call VSP.

Making an Appointment With a VSP DoctorOnce you select a VSP doctor, call his or her offi ce to make an appointment. You do not need an identifi cation card; simply identify yourself as a VSP member.

Covered Services and SuppliesThe plan covers the following vision care services and supplies (up to the amounts shown in the table on page 36):

• Complete eye examination of visual function, performed by a licensed ophthalmologist or optometrist.

• Contact lenses if elected in place of conventional lenses and frames.

• Prescription lenses.

• Frames required for prescription lenses.


Schedule of Covered Vision Care ExpensesServices and Supplies Maximum Covered Expense

Eye examination Paid in full after $15 copayment for VSP doctor services; up to $50 for nonnetwork provider services

Lenses (per pair):

Single vision $50*

Bifocal $80*

Trifocal $95*

Lenticular $155*

Frames $70*

Contact lenses in place of allowances for conventional lenses and frames above

$105*

* VSP doctors offer a 20 percent discount on complete pairs of prescription glasses and a 15 percent discount on contact lens examinations (evaluation and fi tting); you pay the VSP doctor only the excess over the amounts shown in the schedule above. Nonnetwork provider charges for lenses, frames, and contact lenses are reimbursed up to the amounts shown in the schedule above; no discount applies.

Benefi t Payment LevelsThe plan pays benefi ts as shown in the following table:

You will incur an additional charge for noncovered lens options such as lens coatings or hardening, tints, and photochromic, polycarbonate, scratch-resistant, or shatter-resistant lenses. However, VSP doctors offer discounts for noncovered lens options.

Other nonroutine vision care services are not covered under this benefi t, but some may be covered as a medical condition under the UnitedHealthcare coordinated care plan.

Benefi t LimitsBenefi ts are provided for one eye examination every benefi t year and two sets of lenses and two frames every two benefi t years (VSP doctors and nonnetwork doctors combined). The program covers contact lenses when purchased in place of lenses and frames. Any replacement of lost, stolen, or broken lenses and/or frames is subject to the two-set limit.

What the Vision Care Program Does Not CoverThe following vision care expenses are not covered:

• Antirefl ective coatings and tintings.

• Charges for sunglasses or light-sensitive glasses in excess of the amounts covered for nontinted glasses.

• Corrective vision treatment of an experimental nature. Experimental nature means a procedure or lens is not used universally or accepted by the vision care profession, as determined by the service representative.

• Costs in excess of the maximum covered expenses.

• Dyslexia, visual analysis therapy, or training related to muscular imbalance of the eye.

• Medical or surgical treatment of the eyes. (However, VSP doctors offer discounts for refractive surgery.)


• Nonprescription (over-the-counter) glasses.

• Orthoptics or vision training or any associated supplemental testing.

• Plano lenses (less than a ±0.38 diopter power), two pair of glasses in place of bifocals, or extra charges for progressive lenses in excess of the bifocal allowance.

• Services or supplies not listed as covered expenses.

• Services or supplies received more than 60 days after the service representative authorizes the patient’s vision care benefi ts.

• Services or supplies that were received while the individual was not covered under the plan or charges for lenses and frames that were furnished or ordered before the individual became covered under the plan.

• Solutions and/or cleaning products for spectacle glasses or contact lenses.

• Special supplies such as nonprescription sunglasses or subnormal vision aids.

How to Submit a Vision ClaimWhen you receive services from a VSP doctor, identify yourself as covered under the VSP program. The VSP doctor will submit an itemized bill directly to the service representative. You do not need to fi le a claim.

When you receive services from a nonnetwork provider, submit a copy of your itemized bill to the service representative. Be sure to include the covered employee’s name, mailing address, and Social Security number; the group name; and the patient’s name, date of birth, and relationship to the employee. Claims must be fi led within 12 months of the date of service. Claim forms are available on the VSP web site.


Review and Appeal ProceduresThe Plan has established procedures for review and appeal of denied claims or eligibility to participate in the plans described in this booklet.

This section describes claim review and appeal procedures for the UnitedHealthcare coordinated care plan, mental health and substance abuse program, prescription drug program, and vision care program.

Medical Benefi t Claims ProcessEach service representative is responsible for evaluating benefi t claims in accordance with the terms of the Plan and using a reasonable claims procedure in accordance with Federal rules. The service representatives have the right to obtain independent health care advice and to request additional information as necessary to decide your claims.

You will receive a written notice of the claim decision within the time limits described in this section. The time limits are based on Federal laws, the type of claim, and whether or not the service representative has all of the information needed to process the claim.

Your claim will fall into one of these four categories:

1. Preservice claim: a request for coverage of health care benefi ts for which the terms of this Plan require you to obtain prior approval before receiving treatment or services such as benefi ts requiring preadmission review, preapproval, precertifi cation, or predetermination.

2. Concurrent care claim: a request to continue coverage of services that the service representative approved previously as an ongoing course of treatment or to be provided for a certain time.

3. Postservice claim: a request for coverage of health care benefi ts that is not a preservice, concurrent care, or urgent care claim. Generally, postservice claims are fi led for payment or reimbursement of benefi ts for care that already has been received.

4. Urgent care claim: a request for a claim determination needed quickly due to medical exigencies. An urgent care claim is any claim for medical care or treatment with respect to which the application of the time period that otherwise applies to nonurgent claim determinations could seriously jeopardize the life, health, or ability of a patient to regain maximum function, or which—in the opinion of the attending physician—would subject the patient to severe pain that could not be managed adequately without the care or treatment that is the subject of the claim. In addition, if a physician with knowledge of the patient’s medical condition determines that a claim is an urgent care claim, the claim shall automatically be treated as an urgent care claim for the purposes of this provision.

How to File a Claim for Benefi tsGenerally, whenever you receive services from a network provider, participating pharmacy, or member dentist, that provider submits your claim to the appropriate service representative for review and payment; you do not need to fi le a claim for yourself.


If you do need to fi le your own claim, which may be the case when you receive services from a nonnetwork provider, nonparticipating pharmacy, or nonmember dentist, you must submit a written claim form to the appropriate service representative. You can obtain claim forms by calling the service representative, or in some cases, from the service representative’s web site.

You can ask your nonnetwork provider to submit your claim for you, but ultimately it is your responsibility to ensure that your claim for benefi ts is fi led.

Claims must be fi led within 12 months from the date you receive the covered service, treatment, or product to which the claim relates.

Because urgent care claims are so time sensitive and important, you should call the service representative as soon as possible when you learn that you will need immediate care. If you (or your physician) provide all of the information needed to review your claim, the service representative will give you an answer within 72 hours.

Time Limits for Decisions on Benefi t ClaimsThe Federal Government sets time periods for reviewing and deciding health care claims. The service representative will notify you within the following time limits as to whether your claim is approved or denied, in whole or in part. If your claim is denied, you will have the opportunity to fi le an appeal within certain time limits also described here. If your claim is denied due to inaccurate or incomplete information, you can correct or submit additional information with your appeal.

Time Limits for Receiving Benefi t Claim Decisions

Type of claim You will receive notifi cation within . . .But it may be extended for

an additional . . .Postservice claim 30 days after your claim is received 15 days because of matters

beyond the control of the service representative**

Preservice claim* 15 days after your claim is received 15 days because of matters beyond the control of the service representative**

Concurrent care claim

24 hours after your claim is received, provided that a request to extend an ongoing course of treatment is made at least 24 hours before the previous approval expires

Not applicable if you provide enough information***

Urgent care claim* 72 hours after your claim is received Not applicable if you provide enough information***

* If you or your authorized representative fails to follow the Plan’s procedures for fi ling a preservice or urgent care claim, within 5 days (24 hours for an urgent care claim) the service representative will notify you or your authorized representative of the failure and explain the proper procedures.

** If more information is required to review your claim, the service representative will notify you before the end of the initial review period (or within 5 days for a preservice claim) of the specifi c information needed and will allow you at least 45 days to provide that information. The review time periods for preservice and postservice claims will be suspended until the date that you respond to the request for more information.

*** If more information is required to review your claim, the service representative will notify you within 24 hours of the specifi c information needed and will allow you at least 48 hours to provide that information. The review time periods for concurrent care and urgent care claims may be extended for as long as 48 hours from the earlier of (1) the date that the service representative receives the additional information or (2) the end of the time period that you were given to provide the additional information.


If Your Benefi t Claim Is DeniedIf your medical or dental benefi t claim is denied, in whole or in part, the service representative will send you a notice that will include

• The specifi c reasons for the denial.

• A reference to the specifi c Plan provisions on which the claim determination was based.

• A description and explanation of any additional information that is needed to process your claim.

• A description of the Plan’s appeal procedures and the applicable time limits as well as your right to bring legal action if your claim is denied on appeal.

• A statement that you can request, free of charge, copies of documentation that relates to the decision.

• A description of any rule, protocol, or other criterion that was relied on in determining your claim and your right to obtain a copy, free of charge, upon request.

• A statement that you can request, free of charge, an explanation of the scientifi c or clinical judgment that was used if your claim was denied based on a medical necessity, an experimental treatment, or another similar exclusion or limitation.

• For an urgent care claim, a description of the expedited review process applicable to such claims.

In many cases, your physician or other health care provider will send a bill directly to the service representative. If you are required to submit a claim, use the following tips to prevent delays and other claim fi ling problems:

1. Provide all information that is requested on the form, including your full name, address, and Social Security or member identifi cation (ID) number; the patient’s name and birth date; the date of the service; the diagnosis; and the types of services received.

2. Always attach an itemized bill that includes the provider’s name, address, and tax ID number. A notice from the provider that payment is overdue generally does not provide enough information for determining benefi ts and payments.

3. If you are asked to provide more information, be sure to include the patient’s full name and your full name and Social Security or member ID number.

4. If you or a covered dependent is eligible for coverage under another employer’s group benefi t plan, you should submit the claim fi rst to the plan that provides primary coverage (as determined under the coordination of benefi ts provisions). When that plan sends you a written Explanation of Benefi ts form, send a copy of the explanation, the appropriate claim form, and an itemized bill to the second plan. If you are not sure which plan provides primary coverage, submit a claim to both plans at the same time.

How to Appeal if Your Benefi t Claim Is Denied If your benefi t claim is denied, in whole or in part, you may be able to resolve the denied claim through an informal review process. Simply call the service representative and discuss the situation.


If the claim is not resolved with a telephone call, you have the right to fi le a formal (written) appeal with the service representative. You must fi le your appeal within 180 days of the date that you are notifi ed of the denial. To fi le your appeal, you must

• State, in writing, why you believe the claim should have been approved.

• Submit any information and documents you think are appropriate, including any additional information not submitted with your initial claim.

• Send the appeal and any supporting documentation to the service representative at the appropriate claims fi ling address.

You may request, free of charge, copies of all documents, records, and other information relevant to your claim for benefi ts.

The service representative will review your appeal and make a decision. The review will be conducted by a person who did not make the decision on your initial claim and is not the subordinate of that person. The review will include all information you submit and will not give deference to the initial claim decision. If deciding the appeal involves medical judgment, such as determining medical necessity, or if treatment was experimental, a qualifi ed health care professional will be consulted. That health care professional will not be one who was consulted in determining your initial claim and will not be a subordinate of such person. In reviewing your appeal, the service representative will use its discretion in interpreting the terms of the Plan and will apply them accordingly.

The decisions of the service representative are fi nal and binding. Benefi ts will be paid under the plan only if the Plan Administrator decides in its discretion that you have met the eligibility and participation requirements and the service representative has determined you are entitled to the benefi ts.

You can make an appeal for urgent care orally by calling the service representative. (All other appeals must be made to the service representative in writing.)

Time Limits for Decisions on Benefi t AppealsThe Federal Government provides time limits for reviewing and deciding health care benefi t appeals. If the service representative denies your appeal, in whole or in part, you will be notifi ed as follows:

Time Limits for Receiving a Benefi t Appeal DecisionYou will receive notifi cation of the

decision on your . . . Within . . .Postservice claim appeal 30 days for each of two levels of appeal

Preservice claim appeal 15 days for each of two levels of appeal

Concurrent care claim appeal Same as preservice or urgent care appeals, depending on medical circumstances

Urgent care claim appeal Within 72 hours* after your appeal is received* For an urgent care appeal, you can submit information by any timely method, including by fax, telephone, other electronic means,

or orally.


If Your Benefi t Appeal Is DeniedIf your benefi t appeal is denied, in whole or in part, the service representative will send you a notice that will include



• A statement of your right to obtain, free of charge, copies of documentation related to the decision.

• A summary of your right to additional appeals or legal action.

• A statement that you may request, free of charge, identifi cation of medical or vocational experts whose advice was obtained by the service representative.

• A description of any rule, protocol, or other criterion that was relied on in determining your appeal, and your right to obtain a copy, free of charge, upon request.

• A statement that you can request, free of charge, an explanation of the scientifi c or clinical judgment that was used if your appeal was denied based on a medical necessity, an experimental treatment, or another similar exclusion or limitation.

Whom to Contact for Benefi t Claim and Appeal ProceduresYou can obtain a copy of the benefi t claim review and appeal procedures by calling the service representative.

Eligibility Claims ProcessCall the Boeing Service Center if

• You have questions about eligibility.

• You believe that you or an eligible dependent has been improperly denied

• Participation in a health care plan.

• The opportunity to make an election as a result of a qualifi ed status change.

How to File a Claim for EligibilityYou may be able to resolve questions about eligibility for health plan benefi ts by calling the Boeing Service Center. If your question or request is not resolved by telephone (an informal review process), you may fi le a formal (written) eligibility claim. To do so, call the Boeing Service Center and request a claim initiation form.

You can submit urgent care claims for eligibility by calling the Boeing Service Center. You may be required to provide information from your provider to substantiate your urgent eligibility claim.


Time Limits for Decisions on Eligibility ClaimsThe Boeing Service Center will review your eligibility claim and notify you of its decision within the following time frames:

Time Limits for Receiving Eligibility Claim Decisions

Type of ClaimYou will receive notifi cation

within . . .But it may be extended for

an additional . . .Preservice claim* 15 days after your claim is

received15 days because of matters beyond the control of the Boeing Service Center**

Concurrent care claim 24 hours after your claim is received, provided that a request to extend an ongoing course of treatment is made at least 24 hours before the previous approval expires


Urgent care claim* 72 hours after your claim is received


Another claim, including a postservice claim or eligibility claim that does not involve medical or dental services

30 days after your claim is received

15 days because of matters beyond the control of the Boeing Service Center**

* If you or your authorized representative fails to follow the Plan’s procedures for fi ling a preservice or urgent care eligibility claim, within 5 days (24 hours for an urgent care claim) the Boeing Service Center will notify you or your authorized representative of the failure and explain the proper procedures.

** If more information is required to review your claim, the Boeing Service Center will notify you before the end of the initial review period (or within 5 days for a preservice claim) of the specifi c information needed and will allow you at least 45 days to provide that information. The review time periods for preservice and postservice claims will be suspended until the date that you respond to the request for more information.

*** If more information is required to review your claim, the Boeing Service Center will notify you within 24 hours of the specifi c information needed and will allow you at least 48 hours to provide that information. The review time periods for concurrent care and urgent care claims may be extended for as long as 48 hours from the earlier of (1) the date that the Boeing Service Center receives the additional information or (2) the end of the time period that you were given to provide the additional information.

If Your Eligibility Claim Is DeniedIf your eligibility claim is denied, the Boeing Service Center will send you a notice that will include



• A description and explanation of any additional information that is needed to process your claim.

• A description of the Plan’s appeal procedures and the applicable time limits as well as your right to bring legal action if your claim is denied on appeal.

• A statement that you can request, free of charge, copies of documentation that relates to the decision.

• A description of any rule, protocol, or other criterion that was relied on in determining your claim and your right to obtain a copy, free of charge, upon request.

• For an eligibility claim involving urgent care, a description of the expedited review process applicable to such claims.


How to Appeal if Your Eligibility Claim Is DeniedIf your eligibility claim is denied, you (or your legal representative) may fi le an appeal with the Employee Benefi t Plans Committee (the “Committee”) or its delegate.

You must fi le your appeal within 180 days of the date that you are notifi ed of the denial. To fi le your appeal, you must

• State, in writing, why you believe the claim should have been approved.

• Submit any information and documents you think are appropriate.

• Send the appeal and any supporting documentation to the Employee Benefi t Plans Committee:

Time Limits for Receiving an Eligibility Appeal DecisionYou will receive notifi cation of the

decision on your . . . Within . . .Preservice claim appeal 30 days after receipt of your appeal

Concurrent care claim appeal Same as preservice or urgent care appeals, depending on medical circumstances

Urgent care claim appeal Within 72 hours* after receipt of your appeal

Other appeal, including a postservice claim appeal or eligibility appeal that does not involve medical or dental services

60 days after receipt of your appeal

* For an urgent care appeal, you can submit information by any timely method, including by fax, telephone, other electronic means, or orally.

You may request, free of charge, copies of all documents, records, and other information relevant to your claim for benefi ts.

The Committee may require you to provide information from your provider to substantiate your urgent appeal. The Committee has the exclusive right to interpret and apply the terms of the Plan and to exercise its discretion to determine all questions that arise under the Plan. The Committee will review all information you submit, and will not give deference to the initial eligibility claim decision.

The decisions of the Committee are fi nal and binding. Benefi ts will be paid under the Plan only if the Committee decides in its discretion that you have met the eligibility and participation requirements and the service representative has determined you are entitled to the benefi ts.

Time Limits for Decisions on Eligibility AppealsThe Federal Government provides time limits for reviewing and deciding health care eligibility appeals. If the service representative denies your appeal, in whole or in part, you will be notifi ed as follows:

Address: Employee Benefi t Plans CommitteeThe Boeing Company100 North RiversideMC 5002-8421Chicago, IL 60606-1596

Fax: 312-544-2077

Telephone(for urgent appeals): 312-544-2799


If Your Eligibility Appeal Is DeniedIf your eligibility appeal is denied, in whole or in part, the Committee will send you a notice that will include


• A reference to the specifi c Plan provisions on which the appeal determination was based.

• A summary of your right to bring legal action.

• A statement of your right to obtain, free of charge, copies of documentation related to the decision.

• A statement that you may request, free of charge, identifi cation of medical or vocational experts whose advice was obtained by the Committee.

• A description of any rule, protocol, or other criterion that was relied on in determining your appeal and your right to obtain a copy free of charge, upon request.

Whom to Contact for Eligibility Claim and Appeal ProceduresYou can obtain a copy of the eligibility claim review and appeal procedures by calling the Boeing Service Center.

What You Can Do if Your Appeal Is DeniedIf the service representative or the Committee denies your appeal, you may bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974, as amended. However, you must bring any legal action within 180 days of the

• Decision on appeal of your claim for benefi ts or eligibility.

• Expiration of time to take an appeal if no appeal is taken.

For initial claims fi led before January 1, 2005, any legal action must be commenced within two years after the rendering of the services on which the claim is based, or within two years of the date you or your dependent was initially denied participation in the plan.

How Claims Are Paid When You Have Duplicate CoveragePlans that offer medical or dental benefi ts follow certain rules when there is duplicate coverage. For example, if both you and your spouse are working, you or your family members might have duplicate coverage. That is, one or more of you might be enrolled in more than one group health care plan. Other coverage includes, whether insured or uninsured, another employer’s group benefi t plan, another arrangement of individuals in a group, Medicare (to the extent allowed by law), individual insurance or health coverage, and insurance that pays without consideration of fault.

If you or your covered dependents have duplicate medical and/or dental coverage, the two plans must coordinate their benefi ts to determine which plan will be responsible for paying which part of the bill. In this coordination of benefi ts, one insurer will be considered primary (the plan that considers the charges fi rst) and the other will be considered secondary (the plan that considers the charges second). When you fi le a claim, it is your responsibility to know which plan is primary and which plan is secondary for you and your covered dependents.

The primary plan pays its benefi ts fi rst and pays its benefi ts without regard to benefi ts that may be payable under other plans. When another plan is the primary plan for medical coverage, the secondary plan pays the difference between the benefi ts paid by the primary plan and what would have been paid had the secondary plan been primary.


Determine Whether the Plan Is Primary or SecondaryWhen determining whether this health care plan is primary or secondary, this plan applies the following rules. A plan is considered primary when

• It has no order of benefi t determination rules.

• It has benefi t determination rules that differ from coordination of benefi t rules under state regulations, or if not insured, that differ from these rules.

• All plans that cover an individual use the same coordination of benefi t rules, and under those rules, the plan is primary.

If the aforementioned rules do not determine which group plan is considered primary, this plan applies the following coordination of benefi t rules:

1. A plan that covers a person as an employee, retired employee, member, or subscriber pays before a plan that covers the person as a dependent.

2. A plan that covers a person as an active employee or dependent of an active employee is primary. The plan that covers a person as a retired, laid-off, or other inactive employee or as a dependent of a retired, laid-off, or other inactive employee is secondary.

3. If a dependent child is covered under both parents’ group plans, the child’s primary coverage is provided through the plan of the parent whose birthday comes fi rst in the calendar year, with secondary coverage provided through the plan of the parent whose birthday comes later in the calendar year.

4. If a dependent child’s parents are divorced or separated and a court decree establishes fi nancial responsibility for the health care coverage of the child, the plan of the parent with such fi nancial responsibility is the primary plan of coverage. If the divorce decree is silent on the issue of coverage, the following guidelines are used:

a. The plan of the parent with custody pays benefi ts fi rst.

b. The plan of the spouse of the parent with custody pays second.

c. The plan of the parent without custody pays third.

d. The plan of the spouse of the parent without custody pays fourth.

5. If none of the aforementioned rules establish which group plan should pay fi rst, then the plan that has covered the person for the longest period is considered the primary plan of coverage.

6. Continuation coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, always is secondary to other coverage, except as required by law.

7. If you or an eligible dependent is confi ned to a hospital when fi rst becoming covered under this plan, this plan is secondary to any plan (including a Company-sponsored health care plan) already covering you or your dependent for the eligible expenses related to that hospital admission. If you or your dependent does not have other coverage for hospital and related expenses, this plan is primary.

If You Are Covered by Two Boeing-Sponsored PlansBenefi ts under a Company-sponsored medical or dental plan are not coordinated with benefi ts paid under any other group plan offered by the Company, except as described below. You can receive benefi ts from only one Company-sponsored medical or dental plan. However, when dental services performed by a licensed dentist also are covered under the medical plan, the dental plan pays its benefi ts fi rst and the medical plan is secondary.


If You Are Covered by Medicare and This PlanFederal rules govern coordination of benefi ts with Medicare. In most cases, Medicare is secondary to a plan that covers a person as an active employee or dependent of an active employee. Medicare is primary in most other circumstances.

Treatment of end-stage renal disease is covered by the Traditional Medical Plan for the fi rst 30 months following Medicare entitlement due to end-stage renal disease, and Medicare provides secondary coverage. After this 30-month period, Medicare provides primary coverage and the Traditional Medical Plan provides secondary coverage.

Claim AdministrationThe service representative has the right to obtain and release any information or recover any payment it considers necessary to administer these provisions.

When an Illness or Injury Is Caused by the Negligence of AnotherIn some situations, you or a covered dependent may be eligible to receive, as a result of an accident or illness, health care benefi ts from an automobile insurance policy, homeowner’s insurance policy, or other type of insurance policy. In these cases, this plan will pay benefi ts if the covered person agrees to cooperate with the service representative in administering the plan’s subrogation rights.

If a person covered by this plan is injured by another party who is legally liable for the medical bills, the covered person may request this plan to pay its regular benefi t on his or her behalf. In exchange, the covered person agrees to

• Complete a claim and submit all bills related to the injury or illness to the responsible party or insurer.

• Complete and submit all of the necessary information that is requested by the service representative.

• Reimburse the plan if he or she recovers payment from the responsible party or any other source.

• Cooperate with the service representative’s efforts to recover from the third party any amounts this plan pays in benefi ts related to the injury or illness, including any lawsuit brought against the responsible party or insurer.

Conversion of CoverageIf medical coverage terminates for you or an eligible dependent, that person may convert to an individual group medical conversion policy offered by the service representative for your medical plan. Benefi ts under the individual policy will not be the same as benefi ts under this plan, so be sure to read the application materials carefully.

To convert to an individual policy, you must complete a conversion application and submit it to the service representative within 31 days of the date your Company-sponsored coverage ends. You will be billed for the applicable rate, which generally is higher than the group rate. Conversion applications are available from the service representative.

No evidence of insurability will be required.


Defi nitionsAmbulatory Surgical Center An ambulatory surgical center is a licensed public or private facility with an organized medical staff of physicians that is equipped and operated mainly for performing surgery and giving skilled nursing care on an outpatient basis. The facility must have registered nurses on duty when a patient is in the facility and may not provide services or beds for patients to stay overnight.

Audiologist An audiologist is any person whoAudiologist An audiologist is any person whoAudiologist

• Possesses a master’s or doctorate degree in audiology or speech pathology from an accredited university.

• Possesses a Certifi cate of Clinical Competence in Audiology from the American Speech and Hearing Association.

• Is qualifi ed in the state in which the service is provided to conduct an audiometric examination and hearing aid evaluation test for measuring hearing acuity and determining and prescribing the type of hearing aid that would best improve the covered person’s loss of hearing acuity. When a physician performs the services, the physician is considered an audiologist for purposes of this plan.

Calendar Year A calendar year is January 1 through December 31, annually.

Chiropractor A chiropractor is a physician of chiropractic (D.C.) licensed as such by the state in which he or she practices and whose scope of practice is the diagnosis and treatment of the subluxations or misalignments of the spinal column and related bones and tissues that produce nerve interference.

Christian Science Practitioner A Christian Science practitioner is a person authorized to be a Christian Science practitioner or a Christian Science nurse by the Mother Church, the First Church of Christ, Scientist, of Boston, Massachusetts.

Christian Science Sanatorium A Christian Science sanatorium is a facility approved for inpatient care by the Mother Church, the First Church of Christ, Scientist, of Boston, Massachusetts.

Confi ned Confi ned means a person is admitted as a registered bed patient in a facility on the Confi ned Confi ned means a person is admitted as a registered bed patient in a facility on the Confi nedrecommendation of a physician for medical, mental health, or substance abuse treatment.

Convalescent and Long-Term Illness Care Facility A convalescent and long-term illness care facility is

• A ward, a wing, or other specially designated convalescent, chronic disease, or long-stay care unit operated by or under the supervision of a hospital.

• A freestanding institution operating under the laws governing convalescent hospitals for convalescent and long-term illness care. Such an institution must have an arrangement with one or more hospitals for the transfer of patients between the hospital and the facility. It also must be equipped to care adequately for convalescing patients or patients not in need of inpatient hospital care.

Either facility above must be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or must qualify as an extended care facility under Title XVIII of the Social Security Act of 1965, as amended.

The term does not include hospitals, rest homes, homes for custodial care, homes for the aged, or alcohol or drug rehabilitation centers.


Covered Expense Covered expense means only the expense incurred by a person who is covered by the plan for medical services and supplies that are specifi cally allowed by the plan for preventive care or for hospice care or that are

• Prescribed by a physician for the therapeutic treatment of injury, illness, or pregnancy.

• Medically necessary.

• Not in excess of the reasonable and customary charges as determined by the service representative.

Custodial Care Custodial care is the type of care or service that, even if ordered by a physician, is primarily for the purpose of

• Meeting the personal needs of the patient.

• Maintaining a level of function (as opposed to specifi c medical, surgical, or psychiatric care or services designed to reduce the disability to the extent necessary to enable the patient to live without such care or services).

This includes help in walking, bathing, dressing, preparing special diets, feeding, and giving medications that do not require constant attention of trained medical personnel. The plan does not cover custodial care.

Dentist A dentist is a doctor of dental surgery or a doctor of dental medicine who legally is Dentist A dentist is a doctor of dental surgery or a doctor of dental medicine who legally is Dentistlicensed to practice dentistry and prescribe medications within the scope of that license.

Disability or Disabled Disability or disabled means thatDisability or Disabled Disability or disabled means thatDisability or Disabled

• An employee cannot perform the material and substantial duties of regular work associated with his or her age and sex because of injury, illness, or pregnancy.

• A dependent spouse cannot engage in all the normal activities of other people of the same age and sex and in good health because of injury, illness, or pregnancy.

• Any other covered individual cannot engage in all the normal activities of other people of the same age and sex and in good health because of injury or illness.

Note that the defi nition of disability is somewhat different for the purposes of Social Security and COBRA.

Doctor See physician.

Emergency An emergency is the sudden onset of a medical, surgical, or psychiatric condition that manifests itself by acute symptoms of suffi cient severity that, in absence of immediate medical attention, could reasonably result in

• Placing the life of the patient or, by virtue of the patient’s psychiatric illness, the life of another individual in jeopardy.

• Serious impairment to bodily functions or serious and permanent dysfunction of a bodily organ or part.

Home Health Care Agency A home health care agency is a hospital or a nonprofi t or public home health care agency that

• Primarily provides skilled nursing services and other therapeutic services under the supervision of a physician or a registered graduate nurse.

• Is run according to rules established by a group of professional persons.

• Maintains clinical records of all patients.

• Does not primarily provide custodial care or mental health care and treatment of the mentally ill.


In those jurisdictions where licensing by statute exists, the home health care agency must be licensed and run according to the laws that regulate home health care.

Home Health Care Services Home health care services are the care and treatment of a person in his or her home. To qualify, the services must be established and approved in writing by a physician who certifi es that the person would require confi nement in a hospital or skilled nursing facility if he or she did not have the care and treatment prescribed for home health care.

Hospice Facility A hospice facility is an institution or part of an institution that

• Primarily provides care for terminally ill patients.

• Is accredited by the National Hospice Organization or Medicare.

• Fulfi lls any licensing requirements of the state or locality in which it operates.

Hospital A hospital is an institution that meets all of the following criteria. The institutionHospital A hospital is an institution that meets all of the following criteria. The institutionHospital

• Maintains full-time, permanent facilities for the bed care of resident patients.

• Has a physician in regular attendance.

• Provides nursing services by professional registered nurses 24 hours a day, on duty or on call.

• Primarily provides diagnostic and therapeutic services for medical and surgical care of injuries, illnesses, or pregnancies.

• Maintains surgical facilities (not required when the facility is operated primarily for the treatment of the chronically and mentally ill).

• Qualifi es as a hospital, psychiatric hospital, or tuberculosis hospital and as a provider of services under Medicare, if such institution is accredited as a hospital by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

• Operates lawfully as a hospital in its area.

Rest homes, nursing homes, convalescent homes, or homes for the aged are not hospitals under this plan.

Legend Drug A legend drug is any drug required by Federal or state law or by regulation of the state board of pharmacy to be dispensed only by prescription or restricted to use only by practitioners.

Medically Necessary Medically necessary care or treatment is medically necessary only if the medical plan or service representative determines that it meets all of the following conditions:

• It is appropriate for the symptoms and consistent with the diagnosis. (Appropriate means the type, level, and length of service, and the setting in which the service is provided, are needed to provide safe and adequate care and treatment.)

• It is given in accordance with generally accepted medical practice and professionally recognized standards.

• It is not generally considered to be experimental or unproved.

• It is specifi cally allowed by the licensing statutes that apply to the provider who treats the patient.

The plan may designate a professional organization as its authorized representative for assessing the necessity and appropriateness of medical care and treatment.


Mental Illness or Functional Nervous Disorder A mental illness or functional nervous disorder is a condition that is both

• Classifi ed as such in the International Classifi cation of Diseases of the U.S. Department of Health, Education and Welfare (V. Psychoneurotic and Personality Disorders No. 290-315, as amended).

• Considered by the medical profession to be amenable to favorable modifi cation.

Network Provider or Participating Provider A network provider or participating provider is a health care professional, institution, facility, agency, or other organization that has entered into a contract with a service representative to provide medical, mental health and substance abuse, prescription drug, or vision services or supplies at a predetermined cost according to the agreement between the plan or program and a service representative.

The providers qualifying as network or participating providers may change from time to time.

Nurse Nurse means a registered graduate nurse, a licensed practical nurse, or a licensed vocational nurse who has the right to use the abbreviation R.N., L.P.N., or L.V.N.

Ophthalmologist An ophthalmologist is any licensed physician of medicine or osteopathy Ophthalmologist An ophthalmologist is any licensed physician of medicine or osteopathy Ophthalmologistlegally qualifi ed to practice medicine, including diagnosis, treatment, and prescribing of lenses to correct conditions of the eye.

Optometrist An optometrist is any person legally licensed to practice optometry as defi ned by the laws of the state in which the service is provided.

Participating Provider See network provider.

Pharmacy A pharmacy is a business licensed to dispense prescription drugs by one or more pharmacists who are licensed under the laws of the state in which the pharmacy is located. The term “pharmacy” includes a hospital pharmacy.

Physician Physician means any legally qualifi ed medical physician, surgeon, dentist, osteopath, optometrist, chiropractor, psychologist, or podiatrist who is practicing within the scope of his or her license. As used in this booklet, the term includes a social worker or counselor holding a graduate degree in counseling or a related fi eld only when under the direction of a legally qualifi ed physician.

Prescription Drug A prescription drug is a drug dispensed only with the written prescription of a physician, including

• A drug bearing the legend “Caution: Federal law prohibits dispensing without a prescription.”

• Oral or injectable insulin, needles, and syringes.

• A compound medication of which at least one ingredient is a legend drug.

• Any other drug that may legally be dispensed only with the written prescription of a physician.

Reasonable and Customary Charge For medical care, mental health and substance abuse treatment, and vision services from nonparticipating providers, a charge will be considered reasonable and customary if it

• Is the normal charge made by the provider for the service or supply.

• Does not exceed the normal charge made by most providers for the same or similar service or supply in the same geographic area where the service or supply is received.


Service Representative A service representative is an agent who has a contract with the Company to make benefi t determinations and administer benefi t payments under the plan and programs described in this supplement. A list of service representatives can be found in “Where to Get Information,” beginning on page 53. The Company may change a service representative at any time.

Skilled Nursing Care Skilled nursing care is care or services prescribed by a physician and furnished by a licensed registered nurse (R.N.) or licensed practical nurse (L.P.N.). The services may be provided on a continuous basis (as in a hospital or skilled nursing facility) or on an intermittent or part-time basis. The patient must be under treatment and/or convalescing from an illness or injury that requires ongoing evaluation and adjustment of care. The nature of the service and skills required for safe and effective delivery, rather than the patient’s medical condition, determines whether the service is skilled.


Where to Get Information

Boeing Service Center for Health and Insurance Plans, Through Boeing TotalAccessAddress: 100 Half Day Road

P.O. Box 1466Lincolnshire, IL 60069-1466

Telephone: 1-866-473-2016Hearing-impaired callers can access TTY/TDD services by calling1-800-755-6363.You must have your BEMS ID number (or Social Security number) and Boeing TotalAccess password.

Representatives available: Monday through Friday9 a.m. to 8 p.m. Eastern time8 a.m. to 7 p.m. Central time7 a.m. to 6 p.m. Mountain time6 a.m. to 5 p.m. Pacifi c time

Boeing Web: Log on to https://my.boeing.com and click TotalAccesshttps://my.boeing.com and click TotalAccesshttps://my.boeing.com

World Wide Web: Your Benefi ts Resources, through https://my-ext.boeing.comYou must have your BEMS ID number (or Social Security number) and Boeing TotalAccess password.

Services: Participant eligibility processing and records; answers about the cost of coverage, enrollment, and network providers; and other information

UnitedHealthcare Coordinated Care Plan Service RepresentativeAddress for claims and appeals:

UnitedHealthcareAppeal UnitP.O. Box 30432Salt Lake City, UT 84130

Claim questions: 1-800-482-7115314-592-7930

Web site: http://www.uhc.com

Services: Claim administration and network management; answers about medical coverage and claims; and customer service

Mental Health and Substance Abuse Program Service RepresentativeAddress for claims and appeals:

ValueOptionsP.O. Box 1290Latham, NY 12110

Telephone: 1-800-892-1411

Web site: https://www.achievesolutions.net/boeing

Services: Claim administration and network management; answers about coverage, referrals, and claims; and customer service



Where to Get Information (continued)

Prescription Drug Program Retail Pharmacy Service RepresentativeAddress: Medco Health Solutions, Inc.

P.O. Box 2187Lee’s Summit, MO 64063

Telephone: 1-800-841-2797

Web site: http://www.medco.com

Services: Pharmacy network management

Prescription Drug Program Mail Service Pharmacy Service RepresentativeAddress: Medco Health Solutions, Inc. (Medco By Mail)

P.O. Box 3938Spokane, WA 99220-3938

Telephone: 1-800-841-2797

Web site: http://www.medco.com

Services: Mail service pharmacy

Vision Care Program Service RepresentativeAddress for claims: Vision Service Plan (VSP)

P.O. Box 997105Sacramento, CA 95899-7105

Address for appeals: VSP Member Appeals3333 Quality DriveRancho Cordova, CA 95670

Telephone: 1-800-877-7195

Representatives available: Monday through Friday9 a.m. to 10 p.m. Eastern time8 a.m. to 9 p.m. Central time7 a.m. to 8 p.m. Mountain time6 a.m. to 7 p.m. Pacifi c time

Web site: http://www.vsp.com

Services: Claim administration and network management; answers about coverage and participating providers; and other information

Documents

Health Care Plan - Boeing · Health Care Plan Supplement to the Health Care Plans Booklet 2005 United Healthcare ... seven days a week, on line and by telephone